Oak Ridge OBGYN | Prescription Refill

OB-GYN Associates of Oak ridge, P.C. | 988 Oak Ridge Turnpike, Physicians Plaza, Suite 140 | 865-483-7415

Patient Services
Prescription Refill

You can renew as many as 4 presciption from the same pharmacy.

You will need to have your present prescription bottle handy when you compete this form.

Requests received after 3:00 PM will be processed the next business day. For the safety of our patients prescription refills and narcotics may only be authorized during office hours when your chart is available.

Patient First Name:
Middle Initial:
Patient Last Name:
Person completing this form if other than patient
Name:
Relationship:
Patient Contact Information
Primary Phone:
Secondary Phone:
Email:
Date of Birth (mm/dd/yyyy) :
Gender:	Male Female
Insurance:
Name of Insured:
Plan ID #:
Preferred Response:	Email Phone
Clinician:
Pharmacy
Name of Pharmacy:
Was your prescription filled here last time?	Yes No
Pharmacy Phone:
Comment:
Medication 1
Name of Medication:
Dosage:
Frequency:
RX # :
Comment:
Medication 2
Name of Medication:
Dosage:
Frequency:
RX # :
Comment:
Medication 3
Name of Medication:
Dosage:
Frequency:
RX # :
Comment: