Refill Requests

If you have questions, call us at:

Phone:

248-528-1010 then press ext. 2

Fax:

248-528-0202

Or send us an email with form below:

To request a prescription refill please complete the form below. If you are due for your check-up please be sure you already have an appointment made. Requests will be responded to within 24-48 hours Monday through Thursday. Friday requests will be responded to on the following Monday. We are closed on the weekends and holidays.

*denotes required field

*First Name: 

*Last Name: 

*Date of Birth: 

*E-mail Address: 

*I have read and understand the Email Privacy Notice 

*Your Contact Phone Number: 

*Exact Name of Medication: 

*Strength of Medication: 

*How often taken: 

*Name of Pharmacy: 

*Pharmacy phone number: 

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