Fairfield Owl Prescription Refill Form
FirstName:
Last Name:
Phone:
E-mail:
RX Number: 1) Drug Name:
RX Number: 2) Drug Name:
RX Number: 3) Drug Name:
RX Number: 4) Drug Name:
Doctor:
(If Known)
Anticipated Day
of Pick Up:
*Anticipated
Time of Pick Up:
Refill Questions or Comments:
*Please be advised that if you plan to pick up your refill within 2 hours to please call the pharmacy directly. Also, if your prescription refill needs to be reauthorized by your physician, it may take 24-48 hours for the doctor's office to respond to the refill request. Be sure to place your order far enough in advance to allow for these situations.