Requests for medicine refills

If you are running low on your medicines or need a refill, you may use this online request portal. Not all requests can be processed here and we will call you if needed. We do not accept refill request from pharmacies.

Issues like insurance authorizations or medicine changes require a call. Call us if you have been told by your pharmacy that a current prescription is not valid or needs additional information.

Properly completed refill requests will be reviewed and handled within 24 hours. Please call us at 334-396-9100 for all other requests, questions or messages. You can begin checking with your pharmacy in 24 hours, but please allow up to 48 hours before calling the office.

** Please do not send this if you have already called in a request **

Name

First Name

Last Name

Date of Birth

MM

DD

YYYY

Phone

(###)

###

####

Pharmacy

Reason for the request

I have an upcoming appointment but will be out before I am seen

I was recently seen but forgot to ask about this medicine

I was recently seen but my medicine is not at my pharmacy

I was prescribed this before for an ailment that has now returned

Requested medicines

Please call us at 334-396-9100 if you have any other requests or questions.