Prescription Refill Request

To request a refill of a prescription, please complete the information below and click submit. We will contact you to address your request.

We cannot prescribe or refill prescriptions if you have not been seen by us in the last year. If you have not been seen in our office in the last 12 months, please go to appointment request page

Please note that some of the fields of this form are required (*). Please complete the required fields before submitting.

Patient Info * Patient First Name Patient Middle Name or Initial * Patient Last Name

Date of Birth

* Month * Day * Year Parent or Guardian Name (if applicable)

Medication Info * What's the name of the medication you need refilled * What the dosage of this medication? * How often do you take this medication?

Date Last Filled

Month Day Year * Prescribing Physician * Name of Pharmacy * Pharmacy Phone Contact Email * Contact Telephone Preferred Contact Method

Comments

Please provide the name, dosage, and frequency taken for each additional medicine you need refilled.

Healthcare Facilities and Privileges

All of the physicians at Cornerstone Ear, Nose & Throat are Board Certified in Otolaryngology and maintain medical, surgical and/or admitting staff privileges at the following Carolinas Healthcare System, Presbyterian/Novant, and independently owned facilities:

CMC Union, Monroe, NC

CMC Pineville, Pineville, NC

Matthews Presbyterian Hospital, Matthews, NC

Union West Ambulatory Surgical Center, Indian Trail, NC

The Surgery Center at Edgewater, Indian Land, SC

Presbyterian Surgery Center Ballantyne, Presbyterian Medical Plaza, Charlotte, NC

Presbyterian Surgery Center Monroe, Presbyterian Medical Plaza, Monroe, NC.

Arboretum

Monroe

Union County

Prescription Refill Request

Questionaires

Privacy

Pre and Post-Operative Instructions

Healthcare Facilities and Privileges