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.

Secure Patient Registration

Please register online to assist us in providing timely care. It's fast, easy, and it decreases your wait time!

Who should register?

If you have a scheduled appointment and...

You are a new patient
Haven't seen us in the past 6 months
Your health has changed
Your insurance has changed

New Patient Information Form

New Patient Medical History Form

Our Board Certified Otolaryngologists

Learn More About Our Caregivers

Our Charlotte and Monroe, NC Offices

Our offices are open from 9:00 am to 5:00 pm, Monday through Friday.

Arboretum: (704) 752-7575

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Monroe: (704) 289-8220

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Monroe at The Park: (704) 290-5995

We'll add an interactive Google Map for our Monroe at The Park location as soon as it becomes available.

Otolaryngologists specialized in the medical and surgical treatment of ear, nose and throat disorders, and related areas of the face and neck.