Refill Requests*

Medication Refill Request Form - *members only**

Please allow 2 business days for refill requests

* Indicates required field

Name *

First

Last

Date of birth *

Email *

Phone Number *

Address (required if having medication mailed to you) *

Line 1

Line 2

City

State

Zip Code

Country

Medication name #1 *

Dose (ex: 20mg) *

Quantity requested (ex: 90 pills) *

Pick up? *

Medication name #2 *

Dose *

Quantity *

Pick up? *

Medication name #3 *

Dose *

Quantity *

Pick up? *

Medication name #4 *

Dose *

Quantity *

Pick up? *

Please list additional medications if needed. Be sure to include which pharmacy you prefer, if applicable. Thanks! *

Submit

7199 W 98th Terrace, Suite 110
Overland Park, KS 66212
Bldg #3 in Windmill Village
clinic: 913-948-7652
fax: 913-273-2474
hello@healthsuite110.com

Clinic Hours
Monday-Thursday 9am-5pm
Friday 9am - 12pm
After hours by arrangement

2019 Holidays - Clinic CLOSED
New Year's Day - Jan 1
Memorial Day - May 27
Independence Day - July 4-5
Labor Day - September 2
Annual Staff Retreat - August 2
Thanksgiving - November 28-29
Christmas - December 24-27
New Year's Eve - December 31

Privacy policy

Medication Refill Request Form - members only*

Medication Refill Request Form - *members only**