Dr. James K. Fortson - Rx Refill Request

Dr. James K. Fortson - Prescription Refill Request

	Refill a prescription Subject to Dr. Fortson's approval, your existing prescription can be refilled by providing us the information below. The exception to this process is those prescriptions that must be presented in writing because of government safety requirements. Confirmation that we have called your prescription in will be sent to your email address or you will be notified by phone. Please note - prescription refills are not automatically granted. A refill authorization is generated at the sole discretion of your physician. Our physicians all have very busy schedules and at times it can take up to 2 business days for them to review your request. Please make sure you consider this fact when you submit your request or prior to contacting the office for information regarding the status of your request. You may now submit your refill requests electronically by filling out the form below. Once received, staff will review it with the doctor and notify you when the prescription has been sent to the pharmacy.
	NOTE: *Information that is required is denoted by a red next to the box.** Name: Required Patient Name:* Email: Phone: Required Date of Birth: Required Physician: Required* Pharmacy Name: Required Pharmacy Phone #: Required Pharmacy Fax #: Prescription #1 Prescription Number: Medication: * Dosage: Date of last refill: Prescription #2 Prescription Number: Medication: * Dosage: Date of last refill: Prescription #3 Prescription Number: Medication: * Dosage: Date of last refill: Prescription #4 Prescription Number: Medication: * Dosage: Date of last refill: