* Required fields
Name *
E-mail Address *
Medication Name *
Directions Doctor has given you as to how you are supposed to take the medication
1 a day
2 a day
3 a day
4 a day
As needed once a day for sleep
As needed every 4-6 hours for pain
Other
If your answer to the above question was other please explain
How many refills are you requesting
Zero
One
Two
Three
Four
As Needed
Second Medication Name
Directions Doctor has given you as to how you are supposed to take the medication
1 a day
2 a day
3 a day
4 a day
1 a day as needed for sleep
1 every 4 to 6 hours as needed for pain
Other
If your answer to the above question was other please explain
How many refills are you requesting
Zero
One
Two
Three
Four
As needed
Third Medication Name
Directions Doctor has given you as to how you are supposed to take the medication
1 a day
2 a day
3 a day
4 a day
As needed once a day for sleep
As needed every 4-6 hours for pain
Other
If your answer to the above question was other please explain
How many refills are you requesting?
Zero
One
Two
Three
Four
As Needed
Forth Medication Requested
Directions Doctor has given you as to how you are supposed to take the medication
1 a day
2 a day
3 a day
4 a day
1 a day as needed for sleep
1 every 4 to 6 hours as needed for pain
Other
If your answer to the above question was other please explain
How many refills are you requesting
Zero
One
Two
Three
Four
As Needed
Fifth Medication Requested
1 a day
2 a day
3 a day
4 a day
As needed once a day for sleep
As needed every 4-6 hours for pain
Other
Directions Doctor has given you on how you are supposed to take the medication
1 a day
2 a day
3 a day
4 a day
1 a day as needed for sleep
1 every 4 to 6 hours as needed for pain
Other
If your answer to the above question was other please explain
How many refills are you requesting?
Zero
One
Two
Three
Four
As Needed
