Request Medication Refill

If you need a refill on your medication, please submit this form 24 hours before you want to pick it up at our office.

* Name

* Day phone

* Email

* Medications to be refilled:

Actiq

Avinza

Demerol

Dilaudid

Duragesic

Exalgo

Fentanyl patch

Hydromorphone immediate release

Kadian

Methadone

Morphine extended release

Morphine immediate release

Onsolis

Opana extended release

Opana immediate release

Oxycodone extended release

Oxycodone immediate release

Oxycontin

Other

Other Medication

Your Message:

* Type the numbers.