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 Dr. Smith Dr. Garcia Dr. Lee Dr. Johnson Previous Submit request
