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Medication Refill Request

Locations in Legacy-Plano, Plano & McKinney

Medication Refill Request

If you have already reached out to your Pharmacy and have not received a response within 48 hours, fill out the form below.

Information Needed

Medication Refill Request

Patient Name: *

Date of Birth: *

Phone Number: *

Email: *

Provider Name: *

Name of Medication: *

Dose: *

Name of Medication:

Dose:

Name of Medication:

Dose:

Pharmacy: *

Pharmacy Phone Number: *

Controlled Substance *

Yes

No

Please allow 3 - 5 business days for us to process your request if an authorization IS NOT required, otherwise, it could take up to a maximum of 14 days.

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Medication Refill