Request Prescription Refill

Use this form to request a prescription refill for a non-narcotic prescription. Please allow 48 hours to process your prescription refill. We will notify you when your prescription has been called into your pharmacy.

Dr. Zehr is happy to refill any prescription that he originally wrote in his treatment of you. He will not, unfortunately, be able to refill prescriptions written for you by other physicians as this is bad medicine and potentially very dangerous to you.

Prescription Refill Request - By Phone:

Please Call: 239.596.0100.

Prescription Refill Request - Online:

* = Required field

Prescription Information

Known Medication Allergies*

Medication Name*

(e.g. Prevacid)

Dosage/Frequency*

(e.g. 30 mg/once a day)

Quantity*

(e.g. 60)

Medication Name*

Dosage/Frequency*

Quantity*

Medication Name*

Dosage/Frequency*

Quantity*

Medication Name*

Dosage/Frequency*

Quantity*

Pharmacy Name*

Telephone Number*

###-###-####

Location (City/State)*

Additional Comments and Instructions*

Security Code*   

Note: Please enter the Security Code as shown above to submit the form.

Please allow 24-48 hours (excluding weekends) for your prescription refill request to be processed. We ask that you request your medications at least 3 to 4 days before your prescription is due to run out. We will refill prescriptions that are current only (prescribed within the last 3 months).

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