Medication Refill Request

This MEDICATION REFILL REQUEST FORM is for the convenience of our current patients only.

Please Note:

  • It is our office policy that medication refills will only be provided at regularly scheduled follow up visits.
  • This form is intended for urgent medication refill requests only such as situations in which a patient will run out of medication shortly before a scheduled office visit or situations in which an emergency prevents a patient from attending a scheduled office visit.
  • Medication refills will not be authorized in the following situations:
    • You do not currently have a follow up visit scheduled
    • You have not been seen for an office visit for an extended period of time
    • You often cancel or miss scheduled appointments
    • You have an outstanding balance for services received
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Patient Name
This area is reserved. It is ONLY NECESSARY for specific prescription details and refill information. It is not for clinical questions or any other comments and is NOT a way to reach Dr. McGinty. Instead, call the office and leave a confidential message.
NOTICE: The office will be closed on 7/31/23 for administrative purposes. The office will re-open on Tuesday 8/1/23.Contact us.