Prescription Refill Request

Please allow for a 1 to 3 day turnaround time.

Before asking for a refill here, make sure you've spoken with a live person at the pharmacy to make sure you have no remaining refills

Medication name(s)

Dosage
Form (patch, gel, pill, compounded, etc.)
Pharmacy name and address (I need the address not the phone number)
If it is a mail order pharmacy I only need their full complete name (address is not needed)
Refill preference: 1-month or 3-month supply
Your Best contact number
Please let me know if it's OK to use your cell number to text you private or sensitive information regarding your request for quicker completion of your request

Name as it appears in our medical record system

This needs to be the name that you have on your insurance card

First Name

Last Name

Your Email Address

Full NAME and STREET ADDRESS of your preferred pharmacy (no need for an address if it's CVS Caremark, express scripts, OptumRx, amazon, Amazon, cost plus, or any of the mail order

Provide the exact name of each medication that you need including the dosage, the form (tablet gel, patch, compounded, cream, or vaginal tablet or vaginal cream, etc.)

Please include as much detail as possible, so your message can be directed properly. Do not use this for any urgent or emergent matters. Response time may be up to three days.

Your Cell Phone Number

(###)

###

####

Dr. Rabin can text me for further questions about this request

Yes