Family Practice
By Appointment Only
Mon-Fri 8am-4pm
Urgent Care
Mon-Fri 8am-10pm
Sat & Sun 9am-6pm
1794 N. Lapeer Rd.
Suite A
Lapeer, MI 48446
(810)245-6944
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Prescription Refill Request
Prescription refills require 48 hour notice.
Patient Name:
Date of Birth:
Pharmacy Name:
Pharmacy Phone:
If you have more than 3 medications to refill, please submit another form.
Medicine # 1
Name of Medicine:
Dosage:
How often taking:
Medicine # 2
Medicine # 3
