Physician Title*

Physician Practice*

Physician ID*

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{physician_title}
{physician_practice}

Please provide your question or message, then fill in the required information below so that a doctor, nurse, or assistant can contact you with a response.

Your Legal Name:*

First NameLast Name

Your Age:*

Age

Your Sex:*

MaleFemale

Please provide the name of the pharmacy you want us to notify.*

Your pharmacy

The prescription drug name:*

Name of the prescription to be refilled

The prescription dosage:*

The dosage of your prescription

Preferred method of communication:*

PhoneEmail

Phone Number:

A phone number you can be contacted by

E-mail Address:

An E-mail address you can be contacted by

Upon submitting your request you should be contacted by phone or e-mail by a nurse or receptionist. At that time you will be told if your prescription renewal is processed and forwarded to your pharmacy.

This hospital connectivity service is for current and future patients. Affiliated physicians and their immediate associates also have permission to use this service. The possibility exists that some communications or inquiries might not be responded to in a timely manner or at all. This service is not to be used for Emergencies. If you are having an emergency please call 911 or phone your physician.

Hardtner Medical Center reserves the right to prosecute any salesperson or institution using this service for commercial gain or solicitation.

Refill Request

Connect now with..

{physician_title}{physician_practice}

{physician_title}
{physician_practice}