MEDICATION REFILL REQUEST

Preferred Pharmacy *

Patient First Name *

Patient Last Name *

Date of birth *

Patient Home Address *

Patient Phone # *

Patient Email *

Medication Details *

Other Comments:

Do you have an upcoming appointment? *

Yes

No

Important: A follow-up appointment must be scheduled in order to refill your medications.

Please call us at 763-559-1640 to schedule your next appointment.

Prescription Refill Policy