Patient Information

Please Note: This form is to refill prescriptions through the pharmacies at Atrius Health. Please contact your clinician's office if you need a prescription refilled at a pharmacy other than an Atrius Health pharmacy.

* indicates a required field

Patient Name *:
Birth Date *: / /
E-Mail:
 
 

If we need to contact you about your prescription
Telephone *: () -
Best Time To Call:
 

Order Location
Pharmacy Location *:
 
Would you like to sign up for auto-refills *? Yes
No
 
Do you want this order mailed or in-person pickup *?
(If this order is for in-person pickup you will receive a text
or call when the order is ready)		 Mail this order only
Mail this and all future orders
In-person pickup at order location
 

Refill Prescriptions (up to 10 medications)
  • Prescription No.: 8 digits (including leading zeroes) found on the prescription label
  • Medication Name
  • Quantity
  Prescription No. Medication Name * Quantity *
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10.