Pain Management

Prescription Refill

Please complete the information below and press the Submit button. Once your request is submitted, please allow our staff 72 hours to mail your prescriptions TO THE ADDRESS LISTED BELOW.

WE REQUIRE 7-10 BUSINESS DAYS ADVANCED NOTICE TO ALLOW FOR SUFFICIENT MAILING TIME.

ABOUT SSL CERTIFICATES
Your Name:
Your Date of Birth: / /
Your phone number (if we have questions):
Your address:
Would you like an email confirmation that your request was submitted? Yes    No
If yes, please enter your Email address:

Prescription 1
Medication Name (as it appears on the bottle):
Strength of medication:
How many pills do you take at a time:
How often do you take them:
How many pills do you take in a 24 hour period?

Prescription 2
Medication Name (as it appears on the bottle):
Strength of medication:
How many pills do you take at a time:
How often do you take them:
How many pills do you take in a 24 hour period?

Prescription 3
Medication Name (as it appears on the bottle):
Strength of medication:
How many pills do you take at a time:
How often do you take them:
How many pills do you take in a 24 hour period?

Prescription 4
Medication Name (as it appears on the bottle):
Strength of medication:
How many pills do you take at a time:
How often do you take them:
How many pills do you take in a 24 hour period?

Are you taking your PAIN medications differently than prescribed?
If so, please explain:
Additional Comments:
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