Prescription Refill Request Form
This prescription refill form is for existing active patients of TFC Pharmacy.
Patient's Name
*
First Name
Last Name
Patient's Date of Birth
*
-
Month
-
Day
Year
Date
Patient's Phone Number
Please enter a valid phone number.
Physician's Name
*
First Name
Last Name
Prescriber DEA #
*
Physician's Contact No.
*
Please enter a valid phone number.
Prescribed Medicines
Medicine Name
Strength/Dosage
Quantity
Route
1
2
3
4
5
6
7
8
9
10
Additional Notes
Delivery Option
Please Select
Pick Up at Pharmacy
Local Delivery
Mail (additional charges may apply)
Signature
*
Date Signed
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: