Prescription Pick Up Request: 7/28/21
RFC WILL BE HAVING COVID-19 VACCINES AVAILABLE AT THIS CLINIC! Use this link for more information and to register: http://riversidefreeclinic.com/images/Resources/Miscellaneous/RFC_COVID-19_Vaccination_Clinic.pdf

**NOTE** If you require immediate medical attention, please seek help at the Riverside University Health System located at 26520 Cactus Ave, Moreno Valley, CA 92555 or call (951) 486-4000.

ONLY fill out if you are on auto-refill and if you will be going to clinic on 7/28/21 to pick up any medication.

At Riverside Free Clinic, we value the safety of our patients. 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.
¿Es usted un paciente de habla hispana? (Are you a Spanish speaking patient?) *
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