Request for Prescription Renewal - Called to Local Pharmacy

ProMed Physicians Family Practice - Three Rivers

While some medications can be renewed online, other medications such as narcotics, Anti-depressants and anti-anxiety medications may require you to make an office appointment. We will only contact you in the event there is a problem filling your prescription.

Please allow 48 hours to complete your refill request. Any questions regarding your prescription should be directed to your pharmacy.

Thank you for your understanding.

Patient's First Name
Patient's Last Name
Patient's Date of Birth (mm/dd/yyyy) / /
Daytime Telephone Number -
When is the best time to call you?
Patient's Address (City, State, Zipcode)
Name of Primary Physician
Patient's Insurance
First prescription:
Name of Prescription Medication
Dosage (For example, 200 mg)
How often is this medication taken? (For example, twice daily)
Reason(s) for requesting this renewal
Second prescription:
Name of Prescription Medication
Dosage (For example, 200 mg)
How often is this medication taken? (For example, twice daily)
Reason(s) for requesting this renewal
Third prescription:
Name of Prescription Medication
Dosage (For example, 200 mg)
How often is this medication taken? (For example, twice daily)
Reason(s) for requesting this renewal
Fourth prescription:
Name of Prescription Medication
Dosage (For example, 200 mg)
How often is this medication taken? (For example, twice daily)
Reason(s) for requesting this renewal
Fifth prescription:
Name of Prescription Medication
Dosage (For example, 200 mg)
How often is this medication taken? (For example, twice daily)
Reason(s) for requesting this renewal
 
Pharmacy to receive prescription renewal
Address of Pharmacy (Street, City and Zipcode)
Telephone of Pharmacy -
Additional Comments
Select the option that describes this request.

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