Rx Refill Request

Please fill out this form completely.

Please allow at least 48-72 hours after submiting a refill request before calling your pharmacy to see if it is ready for pick-up.

If you have any questions, please feel free to call our office directly at: 586-228-2882.

    Which Doctor do you see? *

    Who is requesting the refill?

    For what medication are you requesting a refill? *