Request Prescription Refills

You will need to have your present prescription bottle handy when you complete this form.
For the safety of our patients prescriptions refills and narcotics may only be authorized during office hours when you chart is available.

All fields except addition information required

First Name*
Last Name*
Date of Birth*:
Doctor*
Requested Rx*
Phone Number*
Pharmacy Phone Number*
Allergies*	Yes No
If yes please give Allergy details
Additional Information

Please note that this form will be sent to us securely. All information is kept confidential and private.
Please allow 24-48 hrs for us to process your request. Prescriptions will not be filled on weekends or holidays.
Requests received after 3:00 PM will be processed the next business day.
All new prescription requests should be called in to our office.
Effective January 1, 2008 we are no longer able fax prescriptions to mail order pharmacies. We will be more than happy to mail these prescriptions to your home. For your convenience, the following link is for new prescription mail order forms: Medco, CVS/Caremark, ldirx.com and Express Scripts.

St. John’s Mercy Medical Center
Creve Coeur, MO
p. 314.993.6401

Progress West HealthCare Center
O'Fallon, MO
p. 314.993.6401

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