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Online Refill Request

For your convenience, we now offer an internet option for information and requests regarding appointment information, scheduling and prescription refills.  
 

 Please complete the following form for your online refill request.

Please Note:  All refill requests require physicians approval

For refill requests by pharmacy please call the pharmacy and have them fax us a refill request to 405.603.8455. 

For written prescriptions that will need to be picked up in the office please call prior to picking up to check status. Please allow 5 business days to process your request for all prescriptions. Thank you.

Patient contact information:

For accuracy and efficiency please submit ONLY ONE medication request per patient.  Thank you.

    Full name:
 * required
 
Date of Birth:
 * required
 
 Contact  Number:
 * required
 
Email Address:
 
Patient Information
Med Mgmt Staff:
 

Name of Medication:

 * required
 

Strength:

 * required
 

Directions:

 * required
 

Last fill date:

 
Pharmacy Name:
 * required
 
Pharmacy phone:
 * required
 
Pharmacy fax:
 * required
 
Pickup:
 
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