Prescription Renewal Form - Reliance Family Care

	Be sure to visit our Patient Center...
	Visit Reliance Family Care
	Visit Locust Family Medicine
	Meet Our Staff & Ask Questions
	Find out what our patients think about us!

Reliance Family Care Prescription Refill Form Please complete all the form fields 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 by phone. If you require an immediate refill or have a question, please contact our office at (678) 272-7280. Please be sure to include all of this information. Failure to do so will make it impossible to fulfill your refill request. *Denotes Required Field
Patient Information
Patient Name *	Date of Birth * format:00/00/0000

Parent/Guardian Name *	Indicate Weight
	(pounds)
Home Phone *	Work Phone

Contact Me During Business Hours at: Home Work
Prescription Information
Obtain prescription information directly from the label on your current prescription vial.
PRESCRIPTION #1
Medication Name *	Dosage (in mgs/mls)

Frequency	Provider


PRESCRIPTION#2
Medication Name	Dosage (in mgs/mls)

Frequency


PRESCRIPTION#3
Medication Name	Dosage (in mgs/mls)

Frequency

Pharmacy Information
Please tell us which pharmacy you would like us to call your prescription into. Please be precise, there are many pharmacies and pharmacy locations. Please Note that for controlled substances the patient must have been seen in our office for a medical evaluation within the past three months. NO EXCEPTIONS.
Pharmacy Name *	Pharmacy Location/Address *

Pharmacy Phone Number *	For Controlled Substances - would you like to have your prescription: Mailed Picked Up

Comments