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Prescription Refill Request Form
APPOINTMENTS: (248) 856.6300
75 Barclay Circle, Suite 115, Rochester Hills, MI 48307
With a dramatic increase in the number of prescriptions filled by our office, we are asking that you include all the relevant details on the following form:
Prescription Refill Request FormAlternatively, you can text your refill request to 248-856-6300 with the following information:
- Child's name and date of birth
- Name of medication
- Strength/dose of medication
- Frequency of medication
- Quantity (30-day or 90-day supply, or other)
- Pharmacy name and address
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