For your convenience, Citrus Hills Medical Center offers its
patients two options for making prescription requests.

1) Call the office
You can request prescription refills over the phone
by calling 746-1358 during our normal business hours.

2) Email a prescription request form
Complete our prescription request form below
and submit it to us electronically.

Be sure to complete the form in its entirety.

Name

Home Phone

Work Phone

Date of Birth

Gender   Male    Female

 

Send the prescription to the following pharmacy:

        Name

        Phone

Was your prescription filled here last time?   Yes    No

 

Finally, fill out the information below
for each prescription you are requesting

Medication name

Dosage

 

Medication name

Dosage

 

Medication name

Dosage

 

And now, submit your request to us: 

 

 

 

 

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