FinkShrink.com | Home of Candida Fink, MD

Navigation

Prescription Refill Request
Please fill out all fields in this form to expedite your refill. Please allow at least 7 days notice before you will be out of medication, to prevent disruptions in your medication regimen. Note that if the patient has not been seen in the office in more than 3 months, you will be required to schedule an appointment before the refill is authorized. Please fill in all fields marked with a *
	Patient Name *
	Date of Birth *
	Address *
	Home, work, and mobile phone numbers and email address *
	Medication name and dosage size *
	How is the medication currently being taken? *
	Has the patient experienced any problems or new side effects since the last refill? If so, please describe. *
	Pharmacy phone number *