Jeri Penkava | Prescription Request
17962
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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:



Would you like the prescription:
MailedPick-up

Name of pharmacy:
Address/zip code:
Phone #: