EnRoute Health

Medication Refill Request - Texas Residents Only

Please correct the errors described below.

Medication refills are for chronic conditions cold sores, genital herpes, HSV only. Controlled substances and behavioral health medications will not be provided. Medications for acute symptom relief such as antibiotics, cough, rash, pain, etc need to be scheduled through an Urgent Care Video Visit. For erectile dysfunction, please complete the ED preliminary request form. Submitting a request does not guarantee a prescription for your request. LIMIT 3 MEDICATIONS PER REQUEST

Patient Information

Exp 2101231234

Medication Information

Exp: Lisinopril 20mgs 1 tab by mouth once a day for hypertension; Lo Loestrin Fe pack birth control

Cold Sores / Genital Herpes Medication Refill

Medication refills are for individuals who have experienced previous outbreaks and have a known history of HSV 1/2 and are requesting a refill for a current outbreak. If you are experiencing symptoms for the first time, please schedule a Video Visit.

Your Doctors Information

Name of practitioner who prescribes the medications you are requesting.
Exp: 2101231234

Pharmacy Information

Exp: Walgreens, CVS, Walmart

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