At LMG Family Practice, we do everything we can to make it easy to take your prescribed medication. Kindly allow our staff three business days to process your prescription refill request. If your refill request is urgent, please call our offices directly.
Please fill in all information as completely as possible.
*Denotes required field.
Patient Information
*
First Name
*
Last Name
Middle Initial
*
Date of Birth
*
Social Security #
*
Return Phone #
*
E-mail
*
Pregnant
Yes
No
Not Applicable
*
Nursing
Yes
No
Not Applicable
*
Prescription to be Faxed to
Pharmacy - name:
Fax #
Phn #
Insurer - name:
Fax #
Phn #
Both
*
Prescribing Provider
select provider
Jonathan E. Beck, D.O.
Sangita Doshi, M.D.
Charles B. Kish, D.O.
Morris J. Kliger, D.O.
Linda A. Nadwodny, D.O.
Jeffrey H. Portner, M.D.
Sharon Gomez, C.R.N.P.
Catherine Shields, P.A.-C.
Prescription Information
*
Drug Name
*
Drug Dosage (mg)
*
Drug Quantity
*
Pharmacy Name
*
Pharmacy Phone #
Additional Comments
Note:
Only one prescription may be refilled at a time. You may refill another prescription, either for yourself or for another patient, after each submission. You will not have to enter the top portion of the refill unless it is for an additional patient.
