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Hilton Health Care
Prescription Request Form
 | 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 receptionists.
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| 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 has been filled. |
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Click here for PDF version to
download/print (PREFERRED)
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Today's Date: ____________________________________________
Patient Name: ____________________________________________
Date Of Birth: ___________________________________________
Name of Medication: ______________________________________
Strength: ________________________________________________
Directions: ______________________________________________
How many do you want: ____________________________________
Number of Refills: _______________________________________
Pharmacy Name: ___________________________________________
Pharmacy Phone Number: ___________________________________
Pharmacy Fax Number: _____________________________________
Fax to: (585) 392-6292
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