Prescription Refill Request
Please be advised that it may take up to 5 business days to process prescription refill requests.  Please plan to avoid any interruption in your medication(s) regimen by requesting a refill prior to running out of the medication or supplement. 
 
Prescription refill requests are accepted Monday thru Thursday (except for holidays) and can be faxed to our office by your pharmacy at (301)668-0017.  Additionally, if it has been more than 6 months since we have seen you, we are unable to authorize a prescription or a prescription refill request without an office visit.
Pharmacy Information: Please tell us which pharmacy you would like us to call your prescription into. Please be precise as there are many pharmacies and pharmacy locations.
Please Note: Controlled substances cannot be called in. These prescriptions must be picked up at our office.  
Please complete the secure form below and press submit.
If there is a problem with your prescription refill request or we require more information from you, we will contact you.  For mail delivery prescriptions, please ensure that your shipping address is updated and correct.  
 
Request your refill today! 
By clicking submit: You agree that the information you provided is correct.  Clicking submit is an  acknowledgment of our policy in regards to the turnaround time required to authorize a refill request.  If you require immediate assistance, please contact the office at (301)668-0002. 
 
We strive to complete refill requests as soon as possible and value your privacy.  Please do not provide any payment information on this form.  If you need to provide current payment information for reordering supplements or medications please contact the office at (301)668-0002.  

Name: *

Email: *

Phone #:

Date of Birth (mm/dd/yyyy): *

Pharmacy: *

Pharmacy Phone: *

Medication:

Dosage:

Additional Prescriptions/Supplements & Dosages:

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182 Thomas Johnson Drive

Suite 100

Frederick, MD  21702

301-668-0002

Monday, Wednesday,Thursday, Friday:

9am-1pm & 2pm-5pm

Tuesday:

9am-1pm & 2pm-6pm