Refill Requests

Medication Refill Request Form - *members only**

Please allow 2 business days for refills.
You will receive a text when refills are ready for pick-up. Thank you!

* 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! *

If not already paid for, I understand that my card on file will be charged for payment at time of pick-up. *

I understand

Submit

2020 Holidays - Clinic CLOSED
New Year's Day - Jan 1
Memorial Day - May 25
Juneteenth - June 19th
Independence Day - July 3
Labor Day - September 7
Annual Staff Retreat - September 18
Thanksgiving - November 26-27
Christmas - December 24-25
New Year's Eve - December 31

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

Medication Refill Request Form - members only*

Medication Refill Request Form - *members only**