Prescription Refill Request Form

Lakeside Dermatology

Please correct the errors described below.

Please fill out this form (completely) to request a prescription refill. We will process your request within 24 – 48 hours, except when the office is closed on weekends and holidays. Any information not filled out may delay the processing time of your request.

• If you have not had an exam within the past year, we cannot refill your prescription.
• You cannot use this form for new prescriptions, narcotics, or changes to an existing prescription.
• If you have a question regarding a prescription, please call the office directly. We will not correspond via email or text.
• We will contact you by phone if there is a problem processing your request.
• Confirm with your pharmacy prior to picking up your prescription, to make sure it is ready.
• If you need immediate assistance, please call Lakeside Dermatology directly.

(Please refer to prescription bottle for correct spelling & dosage)

Add new Drug

Your information will be encrypted.