Evergreen Family Health | Williston, Vermont

Request a Prescription Refill

This E-Refill prescription request should allow us to accurately and efficiently handle your medication needs within 1-2 days. Please contact the pharmacy before attempting to pick up your medications. After receiving your request, our clinical staff must review your Health Record. Additional information may be necessary, or you may be asked to schedule a visit before your medication is continued.

Please provide us with all necessary information about your prescription.

Please fill out each segment of this form

Fields marked ( * ) are required

Name:

First: *

Last: *

Date of Birth:

Day: *

Month: *

Year: *

Email: *

Home: *

Phone:

Work:

Cell:

Medication Name: *

Strength: *	mg
Pills Per Dose:
Doses Per Day:

Pharmacy Name:*

Pharmacy Location:*

Primary Practitioner: *

I would like the Prescription Filled by:

Day:

Month:

Time of Day:

Comments:

PLEASE NOTE: THIS REQUEST USES ROUTINE INTERNET MAIL. WE DO NOT GUARANTEE THAT THIS COMMUNICATION WILL BE SECURE AND PRIVATE. If you wish to ensure privacy, contact us by phone or fax instead.