Online Prescription Refill Request Form

This form will send an email to The Light Clinic, PC with the information you provide below. We will respond as soon as we can that we have processed your request, or need you contact us before we can proceed. If you do not receive an answer within 1 business day, please call our office instead- technology can save us time, but isn't perfect!
If the Doctor has any further questions about your request, he will contact you. If you need this refill processed in less than 1 business day, please call the office directly. When we complete your refill request, we will email you a notification if you have provided an email address, otherwise we will attempt to call you and let you know.
Even though this form will not be handled after hours or on a weekend, we want to tell you that for your safety, it is our policy to not call in narcotic pain medication after hours or on weekends. Severe pain that requires narcotics should be evaluated by a physician.
Also, ALL controlled substances will now require a written prescription that you can pick up at the clinic after submitting this form. You can also call us directly during clinic hours and in either case may be required to schedule a visit with a physician or nurse practitioner. Also, for your safety, it is our policy not to call in narcotic pain medication after hours or on weekends. Severe pain that requires narcotics should be evaluated by a physician.
Please remember that email communications are not guaranteed to be private. After receiving them, we handle them with the same attention to confidentiality we give all your medical records, but email replies may be seen by others with access to your computer, including your employer, depending on where you send it from and where you have us reply to.
Thank you.

Name
E-mail (required)
Work Phone
Home Phone
Your birthdate
Your account number

Describe the presciption you wish to refill:

Drug name
Current Dosage (ie. 10mg 3x per day)
How long have you been taking it?
Was this originally prescribed for you by a provider at The Light Clinic? Yes No
Further explanation if required
(ie. Pharmacy's Rx number from bottle)

Where would you like to have the prescription called into (leave blank if you want to pick up a paper prescription at our office):

Name of Pharmacy
Phone with area code