17722 Talbot Road South
Renton, WA USA  98055
Appointments  425.228.0722
Fax  425.271.2566
Business Office  425.271.4303





 

 


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Prescription Refill Requests

In most cases, your health care provider has written a prescription for you for one year.  

In all cases, we ask that you please call your pharmacy before making a refill request.  If your pharmacist has a question, he will call our office.  

This will save both you and our office time!

If you know you need your doctor's permission for a refill, please use this form.  Your request will be e-mailed to our office.
Your prescription refill request (e-mail message) is sent to our clinic via the internet. Although we feel confident your messages to our clinic are secure,  the internet offers no absolute guarantee of confidentiality in regard to e-mail.  Please consider this fact when sending sensitive information.

If you like, you may call our office at 425-228-0722

 

Pharmacy Information:

Pharmacy Name: 


Location of Pharmacy:


 Daytime Phone Number:

 

Prescription Information
(Please include dosage)
  

 

Patient Information

Name:

Date of Birth:

Address:

Daytime Telephone:

E-Mail:

Physician: