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Saint Joseph Mercy


PRESCRIPTION REFILLS

If you have registered and obtained a PIN, you may use this form to request refills for medications prescribed by your AAHOA physician.  Please select the medication(s) from the list below or type them in the box.  Indicate whether you fill your medications monthly or mail away for a 90-day supply.  Allow 2 business days for us to call in prescriptions and 3-5 business days to receive prescriptions by mail.  Check with your pharmacist to be sure the medication is ready before you go to pick it up.

Please note the following:

bullet All required information must be provided including your PIN.
bulletYou may not use this form to request refills for pain medications (such as Vicodin,  Darvocet, Tylenol with codeine, morphine, Percocet, Oxycontin, Duragesic, etc.), sedatives (such as lorazepam/Ativan) or sleeping pills (such as Ambien).  Please call the office if you need refills for these medications.
bulletWe will not refill medications prescribed by other physicians.
bulletIf you require your medication urgently, please call the office – do not use this form.
bulletWe will not refill prescriptions if you have missed your last appointment and not rescheduled it or if an AAHOA physician has not seen you within the last 12 months.

ONLINE PRESCRIPTION REFILL FORM *Required form fields

*PIN Number  What's This?

*Full Name

*Date of Birth (mo/day/year)

*Daytime Telephone Number with Area Code

*Email Address

*Re-enter Email Address

Your Physician is: *

Supply Needed: *

Frequently requested prescription refills: Use the ctrl key for more than one selection.

Other prescription refills:

Prescription Number 1 (Include drug name, strength, and directions on bottle)

Prescription Number 2 (Include drug name, strength, and directions on bottle)

Do you want these prescription(s): *

If chose to have your prescription(s) to be mailed to you. Please fill in these fields:
Street Address:   
City:    State:   Zip Code:  

If chose to have your prescription(s) to be called-in to your pharmacy. Please fill in these fields:
Pharmacy Name:    
Pharmacy Address (street name & city):
Pharmacy Telephone Number: *

If you have started taking any new medications (not prescribed by one of our physicians) in the last year, please indicate them below:
New Medications

Please indicate all medication allergies below. If you have no medication allergies, type "None."
Medication Allergies

Are you currently taking Coumadin (Warfarin)? *

 

Ann Arbor Hematology Oncology Associates, P.C.
734-712-1000
Saint Joseph Mercy Cancer Center
Ypsilanti, Michigan

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