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Refills

Controlled II Medication Refill Request

Please note:  All refill requests require physician approval.  Please allow 2 business days for response.

For non-controlled medications, please call your pharmacy and have them
send a refill request electronically or via fax to 405.285.2280.

Only submit one medication per request.

                                                       

PATIENT INFORMATION:
Medication Refill: Y or N: *
First Name: *
Last Name: *
Date of Birth: *
Phone Number: *
MEDICATION INFORMATION:
Medication: *
Refill Request Comments:

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