Prescription Refill Request

Prescription Refill Request
For medication refills only, for current UACC patients. Not for urgent medical problems — if something feels urgent, call (508) 771-9550. For emergencies, call 911. Refills of controlled-substance prescriptions may require an appointment — we'll contact you if that applies.
Your Name

First NameLast Name
Date of birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Mobile phone
The number we should reach you atFormat: (000) 000-0000.
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Are you a current UACC patient?
Refills require an active care relationship. Please visit our request an appointment pageto schedule.
Medication name(s)
Exactly as printed on the bottle. One medication per line.
Dose / strength, if known
e.g. 20 mg
Pharmacy name
Pharmacy address
Anything we should know?
Please don't use this form for urgent issues.
How should we confirm it's done?
Email
example@example.com
Confirmation consent
Should be Empty: