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Please print out this form to use when requesting a prescription refill fromour office. This will help insure the accuracy of your prescription. If youwould prefer, you may fax us this form and avoid our voice mail system orneed to speak with one of our telephone operators.
Our fax number is: (585) 392-6292
Please allow 24 hours for your prescription to be transmitted to your pharmacy.We recommend you call your pharmacy before picking up yourprescription to verify it being filled.
Today's Date: ____________________________________________ Patient Name: ____________________________________________ Date Of Birth: ___________________________________________ Name of Medication: ______________________________________ Strength: ________________________________________________ Directions: ______________________________________________ How many do want: ________________________________________ Number of Refills: _______________________________________ Pharmacy Name: ___________________________________________ Pharmacy Phone Number: ___________________________________ Pharmacy Fax Number: _____________________________________
Thank You!Hilton Health Care |
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Send mail to
webman@hiltonhealthcare.com with
questions or comments about this web site.
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