Avenue, Waycross GA 31501,
Existing patients only.
Prescription Refill Request
Patient's Full Name:
Date of Birth: (enter 4 digit year)
Patient's Social Security Number:
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:
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.
information e-mail us.© 2004 Kandallu R. Ramesh, M.D., P.C.
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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.