P r e s c r i p t i o n   R e f i l l s
 

For your convenience, we are happy to provide you with prescription refills prior to your next appointment. Any request for a prescription refill will be processed by the end of the next business day. We ask that you do not wait until your prescription has run out before requesting a refill. You must provide all the following information to ensure that your request can be processed. Accuracy of information is very important. If you experience any difficulty using this service, please call our office at 248-465-4163. As always, we ask that you bring all of your medication bottles with you to your appointments so that we may verify that you are receiving the correct medications.

Prescription Refill Information:

Today's Date
Patient Information:
First Name
Last Name
Middle Initial
   
Patient Date of Birth
   
Patient Home Phone Number
Alternative Phone Number
Pharmacy Phone Number
Park Internal Medicine Physician
Choose Method of Refill:
(You can only choose Fax method if you have used it  in our office previously)
Medications:
Medication # 1  
Name
Dosage
Instructions
Quantity
   
Medication # 2  
Name
Dosage
Instructions
Quantity
   
Medication # 3  
Name
Dosage
Instructions
Quantity
   
Medication # 4  
Name
Dosage
Instructions
Quantity
 










   
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