Prescription Refill Backup Request
If you submit this form Tuesday - Friday before 4pm Claire will be notified via email and will work on it that day (excludes Monday and major holidays). When submitted after 4pm it will be addressed the following weekday (excluding Monday). Any submissions on Saturday - Sunday - Monday will be addressed on Tuesday (excluding major holidays)
Email address *
This form is to be used as a backup to making a timely (2 full business days or more) refill request. if you haven't made a refill fax request with your pharmacy we recommend doing so before submitting this form (Fax: 855-808-4055). Refill requests made less than 2 full business days of when you need it or without contacting your pharmacy first will be subject to a $20 urgent prescription processing fee. Sending this backup form at least 2 full business days before you need your prescription will ensure that doesn't happen.
Please provide your name and telephone number *
Your answer
Did you call your pharmacy and request a fax (855-808-4055) refill request? *
If you answered yes what date did you call them on? *
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Please provide your date of birth *
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Please provide your pharmacy's telephone number. *
Your answer
Please provide the medication(s) needing a refill. Include the dosage of each pill. *
example: zoloft 25mg, diazepam 10mg, trazodone 50mg, etc.
Your answer
Please include when you take your pills and how many each day *
For example: 1 pill in the morning and at night :: 2 pills at night :: 1 pill 3 times a day with 1 pill extra if I need it.
Your answer
By what date do you need to have this medication? *
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In order to provide greater protection for your protected health information only your provider Dr. Mantz/Dr. Le has direct access to your chart and it's treatment plan. Therefore until your pharmacy is able to get it right and fax us appropriately, when you submit this form please include all the answers to the questions above so that we can call your pharmacy in case they do not fax us in a timely manner. If you run out of medications and forget to make a request during office hours other options would be to go to an urgent care center, another medical doctor who provides weekend coverage for prescription refills, or to the ER to get a partial refill to cover you through the weekend. Thank you.
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