Plymouth Family Physicians - Prescription Refill Request

Prescription Refill Request

NOTE: If you are requesting a refill for high blood pressure, diabetes or a thyroid condition and are not up to date in your labs and/or appointments, we will only refill your prescription for 30 days. This is for your health and safety. Your cooperation is appreciated.

Healthcare Provider

Dr. Mary Arenberg
Dr. George Schroeder
Mary Reszczynski, FPNP

Name (required)

E-mail Address

Daytime Phone

Pharmacy

Location

Name of 1st Medication

Dosage

Comments:

Name of 2nd Medication

Dosage

Comments:

Name of 3rd Medication

Dosage

Comments:

Name of 4th Medication

Dosage

Comments:

Name of 5th Medication

Dosage

Comments:

Name of 6th Medication

Dosage

Comments:

NOTE: We will attempt fulfill all refill requests within 24 - 48 hours.

I understand that the information on this page will be sent to Plymouth Family Physicians, S.C. and that this submission is not secure. If you are concerned, don't click the Submit button and PRINT THIS FORM or SAVE IT AS A FILE after completing it. You can then mail it or drop it off at the office. If you choose to complete this form at the office, please arrive at least 30 minutes before your appointment to complete all paperwork.