Online Prescription Refill

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2715 Osler Drive,
Grand Prairie, Texas 75051

Tel: 972-206-2940
Fax: 972-602-7261

Email : pacgpa@emcaturaymd.com

Hours:
Monday – Friday
8:00 a.m. – 5:00 p.m.

Online Prescription Refill

To request a prescription refill of a medication, please complete ALL FIELDS of the secure form below. Your request will be processed within 48 business hours and available by one of the following methods of your choice at that time: pick up prescription; or call in prescription. If your request is received on a Friday or a holiday, your request may be processed the following business day. Please note that only ESTABLISHED patients may use this form. Established patients that have not been seen in the office for more than 3 months must make a follow up appointment before any prescriptions can be refilled. If you are a NEW patient, please call our office to schedule an appointment with one of our physicians. Should you need further assistance, please contact us by phone. Read terms and conditions below. Patient Information (Fields are below – and all are required fields)

Medication Information Please note that controlled substances (i.e. ADD/ADHD Medications) are
PICK UP ONLY.

Medication #1
Generic	yes no
Dose:
Instructions:	Pick up prescription
	Call in prescription
Pharmacy Name:
Pharmacy Phone:
Known Drug Allergies:

Person Requesting Refill

Person Requesting Refill
Contact Information

Phone Number:
	Work Home Cell
Address:
City
Zip:
Comments:

Terms and Conditions Submission of this form does not ensure delivery. Only ESTABLISHED patients may request a prescription refill via this format. If you are an established patient and has not been seen by one of our physicians in over 3 months, you must make a follow up appointment in order for the refill to be processed. NEW PATIENTS MUST MAKE AN APPOINTMENT with one of our physicians before any refill can be approved and/or processed. If staff from Pediatric and Adolescent Center of Grand Prairie & Arlington (PACGPA) has not responded to your online request within 48 business hours, please contact the clinic by phone at 972-206-2940. It is also the policy of PACGPA that Antibiotics cannot be refilled. Controlled substances (i.e. ADD/ADHD Medications) must be picked up in person.

I agree to the terms and conditions as outlined above.

Established Patient
Patient First Name
Patient Last Name
Date of Birth
Email Address