Please Remember:    This service is for only those prescription refills that will be phoned in to your pharmacy. You must still phone our office if you require a 90 day written prescription refill. All information needs to be included. Accuracy is very important. If there are any difficulties using this service, please call (248) 267-5000.  
   
  Prescription Refill Information

  
  Today's Date: (MMDDYY - example: 041871)
  
 

Patient's Name:

   
  First:    
  Middle Initial:    
  Last:    
  Patient's Date of Birth:   (MMDDYY - example: 041871)  
  Patient's Phone Numbers:  
  Home:  (Area Code)    
  Work:  (Area Code)  
  Troy Internal Medicine Physician:    
  Pharmacy Phone Number: (Area Code)   

 
  Medication

  
  Medication 1 Name:  
  Dosage:  
  Directions:  
  Quantity:    Number of Refills:    
 
  Medication 2 Name:  
  Dosage:  
  Directions:  
  Quantity:    Number of Refills:    
 
  Medication 3 Name:  
  Dosage:  
  Directions:  
  Quantity:    Number of Refills:    
 
  Medication 4 Name:  
  Dosage:  
  Directions:  
  Quantity:    Number of Refills: