Prescription Pick Up Request: 8/26/20
ONLY fill out if you are on auto-refill and if you will be going to clinic on 8/26/20 to pick up any medication.

At Riverside Free Clinic, we value the safety of our patients. In such confusing times, we understand that some of our patients are nervous about attending clinic to pick up their prescription. In order to help you feel more comfortable, we are providing a quick prescription pick up option. This allows you to skip the waiting times. In order to have your prescription ready for you please fill out this form.

** Any information shared on this form will remain private to follow HIPAA compliance and privacy rights, yet due to the Covid-19 extenuating circumstances we cannot ensure total privacy.
Name (of Patient) *
Birth Day (DD/MM/YYYY) *
Phone Number ( of Patient)
Last Clinic you attended?
Do you need more blood glucose test strips and lancets? *
If yes, how many times do you check your blood sugar levels per day?
If you need glucose test strips, please indicate if you need tiny strips or regular strips?
Clear selection
Please let us know which type of lancets you use.
Clear selection
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