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Please print out this form to use when requesting a prescription refill from our office. This will help insure the accuracy of your prescription. If you would prefer, you may fax us this form and avoid our voice mail system or need 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 your prescription 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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