Jeri Penkava | Prescription Request
17962
page-template-default,page,page-id-17962,_masterslider,_ms_version_3.8.1,ajax_fade,page_not_loaded,,paspartu_enabled,qode-theme-ver-11.0,qode-theme-bridge,wpb-js-composer js-comp-ver-5.4.5,vc_responsive

Prescription Request

Fill this contact form for prescription refill requests, medication questions, prior authorization requests, lab orders, or if you need a referral for therapies or another specialist. Controlled medication requests are processed on Mondays and the prescription will be available for mailing or pick-up on Tuesday. Please have your refill request sent by Monday opening (9AM). There is a $10.00 fee for controlled medication prescription handling and documentation in between appointments.

    Full Name: (required)
    E-mail: (required)
    Phone: (required)
    Address:
    Address 2:
    City:
    State:
    Zip:

    Full Name: (required)
    Birth Month:
    Birth Day:
    Birth Year:
    Current Insurance:
    Guarantor:
    Policy or ID #:
    RX Bin/PCN/Group #:
    Controlled medication requested:
    Other:
    30-60-90 day:
    Check one: BrandGeneric
    Mg/unit:
    Other:
    Form:
    How many / dose and times / day:



    Name of pharmacy: (required)
    Address/zip code: (required)
    Phone #: (required)