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101 Darling Avenue, Waycross GA  31501, 912-287-1297 


 

Prescription Refills

Existing patients only.

Prescription Refill Request

Patient's Full Name:

Gender:
Male Female

Date of Birth: (enter 4 digit year)

Patient's Social Security Number:

Street Address:

City:

State:

Zip Code:

Home Phone:

Work Phone:

What is the name of the prescription drug that you wish to refill?

What is the date of your last refill, as shown on your prescription container label?

If your container is not available, please indicate:
No Container

What is the name of the pharmacy where you wish the prescription refilled?

What is the pharmacy's phone number?

If you wish to have the prescription refilled at the pharmacy you most recently purchased it from, please provide the prescription number printed on the container label.


For more information e-mail us.
2004 Kandallu R. Ramesh, M.D., P.C.

Any information provided on this Web site should not be considered medical advice or a substitute for a consultation with a physician. If you have a medical problem, contact your local physician for diagnosis and treatment.


        
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