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)

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