Pediatrician | Frisco Plano | Internist | Primary Care Physicians | McKinney

For prescription refills, please fill in ALL FIELDS below. Your request will be processed within two business days and available for pick-up from our office or for call-in to your pharmacy. For certain medications and controlled substances, you may be asked to pick up your refill prescription in person.

Please note that your doctor may decline your refill request or may require you to come in for a follow-up appointment before writing your refill prescription.

This service is for refills of prescriptions originally written by one of our physicians only. If you are a new patient, please schedule an appointment so that you may be seen by one of our physicians.

Contact us if you do not hear from us after two business days, if you need your prescription refill sooner or if you need assistance.

patient

First Name

Middle Name

Last Name

Suffix

Date of Birth

E-Mail Address

Street Address

City

State

Zip Code

mEDICATION

Name of Medication

Unit Size (examples: 20 mg, 10%, etc.)

Generic?
Yes No

Dosage

Known Drug Allergies

Prescribing Physician

Instructions
Pick-up Call-in

Name of Preferred Pharmacy

Phone

Street Address

City

State

Zip Code

PERSON REQUESTING REFILL

Name	Relationship to Patient

Address Same as Patient
Street Address

City

State

Zip Code

Home Phone

Cell Phone

E-Mail Address