Step 1. Contact Information This form is confidential and HIPAA compliant First Name Last Name Phone Number E-mail Go back Next Refill request may take up to 72 hours to complete Days of medication left on hand Previous Next Most medication refills will require a monthly appointment with your Primary Provider. Refill requests will not be processed if Patient does not have a follow up appointment scheduled. If you need a controlled substance evaluation appointment, please submit your request on our appointment tab or call the office phone number at (818) 600-2034. Controlled substances, such as benzodiazepines and some ADHD medication will only be filled for a 30 day max supply as per state standards. Medication Requested and dosage Previous Next Please provide your current preferred pharmacy Previous Next Please provide your current preferred pharmacy Your Primary Provider? Select provider Dana Markee Emily Ashley Ibrahim Farooque Azam Nsreen Jesri Michael Joanitis Tiffany Cooper Yulia Koba Antoniadou Steven Berry Clarito Villanueva Emiliano Baquir Kalpesh Bhavsar Sherwin Wong Wendi Sellers David Gueringer Adison Buongiorno-Smith Juliane Lovich Amanda Berkowitz Jeanne Sandoval Joel Price Madison Lawrence Stanley Mesen Wendy Romo DeAdra Jordan Rubicela Rodriguez Anna Hadlock Anna Sealander-Hulbert Marlon Carlo Estella Jeni Massi Alenika Andreev Kathleen Kim Hannah Song Kook Elisa Fry Leonard Christiana Robinson Jasmin Alfonso David Sudyka Pennie Alvarez Trenise Rahman Gayane Melikyan Adriana Estella Guarderas Anthony Carletello Elizabeth Wray Jessica Perez Amanda Romero Brianne Flexen Julie Wions Xiomara Morales Sathi Datta Previous Submit request
