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Please read and become familiar with our Prescription Refill Policy

After filling out form completely; attach form to an email and send it to:     prescription@mypchc.net

Click on the link below to go to the formRequires Adobe Reader to Open       Get Acrobat Reader web logo  

All prescription refill requests require the following information for your safety:

1.  Full name, as appears on your insurance card.

2.  Your birth date.

3.  A telephone number where you can be reached.

4.  The complete name of the medication.

5.  The dosage of the medication.

6.  The frequency with which the medication is taken.

7.  The name and telephone number of your pharmacy.

8.  Any medication allergies.

9.  A list of all other medications both prescribed and non-prescribed that you are taking

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