Jeri Penkava | Established Patient Prescription Request
17962
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Established Patient 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)