Prescription Refill

The office will check each morning between 6:30 and 7:30 am Monday through Friday for new refill requests. Your prescription will be available after 48 hours from the time you placed your request. Prescriptions requested on Friday after 7:30 am or over the weekend will be available on Monday after 4pm.

* Required Field

If you require a same day prescription refill there will be a $10.00 processing fee charged to your account.

Please provide the following contact information:

Contact Information

Name *
Date of Birth *
Home Phone *
Email *

Name of your Provider *




First Prescription To Be Refilled
Name *
Strength or MG *
How Taken *
If other, please specify
Number of days supply needed *
Number of refills requested


Second Prescription To Be Refilled
Name
Strength or MG
How Taken
Number of days supply needed
Number of refills requested


Third Prescription To Be Refilled
Name
Strength or MG
How Taken
Number of days supply needed
Number of refills requested


Pharmacy Information
Name *
Address *
Phone Number


Comments




   


© 2008 General Internal Medicine. All Rights Reserved.
2301 Columbia Avenue Lancaster, PA 17603
Phone - 717.397.2738 Fax - 717.397.7634

site design by: adapoint