Prescription Refill Request

All prescription refill requests will be processed within 1-2 business days after being received.

For hormone or birth control refills, your annual exam and pap smear should be up to date or
you should have a scheduled appointment soon.

The best source for this required information is the label attached to your current prescription.
For urgent needs, please call the office directly at (626) 304-2626.

Patient Full Name:
Date of Birth:
Home Phone:
Work Phone (or daytime phone #):
Email Address:
Pharmacy Name:
Pharmacy City:
Pharmacy Phone:
Medication Name:
Medication Dosage (one pill, or # of mg., etc.):
How often: once a day
twice a day
three times a day
four times a day
as needed
Refill quantity:
Prescribed by (we only refill prescriptions written by us): Dr. Jick
Dr. Chang
Diane (RNP)
Refill Number (if available):