Prescription Refill Request Form

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.

Today's Date

Time

Patient's Full Name

Date of Birth

Primary Phone #

Alternate Phone #

Email Address

Select Prescribing Physician

Michael J. Rogers, M.D. Alexander W. Kennon, M.D. Brooke E. Rogers, DNP, FNP-C Barbara A. Ross, ARNP-C

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

Drug Name

Strength

Add new Drug

Pharmacy Name

Pharmacy Phone #

Pharmacy Location

Comments / Notes

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