Medication Refill Form
Patient Name
*
First Name
Last Name
Patient Phone Number
*
Date of Birth
*
-
Month
-
Day
Year
Date
Allergies
Patient Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
BHRC Clinic
*
Please Select
Frisco
Highland Park Transfer
Southlake
Flower Mound
Fort Worth
Are you due for Labs?
Yes
No
Available time/date for labs
Medication Refill
*
Additional Information
*
I confirm that the information provided is accurate and that I am requesting a refill of my prescribed medications.
*
I authorize Beverly Hills Rejuvenation Center to charge the payment card they have on file for my account.
Submit Refill Request
Should be Empty: