Email Request for Prescription Refill   
First name:
 Last Name:
Email:
 Phone:
Date of Birth:
 Physician that provided
your last prescription?
MM/DD/YYYY
----------------------------------------------------------------------------------------------------------------
Dose
(See Note 1)
 When Taken
(See Note 2)
Medication Name
1.
2.
3.

Note 1 -  "Dose" is often a number with "mg" or "mcg" after it.

Note 2 - "When taken" may be: daily, twice a day with breakfast and dinner, etc.
Pharmacy Name:
 Pharmacy Phone:
Additional information that may be needed to fulfil your prescription request:
I understand that my prescription request will be sent by regular email and
accept Dr. Neighbors' office email policy.
We provide email as a convenience to current patients.   If our office web site and email policy does
not meet your privacy needs then  contact us by phone, regular mail or just stop by to discuss your
need with our friendly staff.
A $25.00 fee is charged for prescriptions not filled during an office appointment.