Prescription Refill Request

You may submit your request for a prescription by completing this “Prescription Refill Request” form below, or by calling our Prescription Line at (412) 369-4000, Ext. 304 during regular business hours, Monday - Friday 7:00am-4:00pm.

All prescriptions are electronically submitted to your pharmacy during our regular business hours. Once approved by your treating provider, we typically submit within 24 business hours of your request. Please contact your pharmacy after 24-48 hours to confirm they have received/filled your prescription prior to pick up. If you are having side-effects from your medication, please call our Prescription Line at (412) 369-4000, Ext. 304 during regular business hours. After 4:00pm weekdays and on weekends/holidays call (412) 430-3320 to reach our Answering Service to be connected to a provider.

So that we can process your prescription request in a timely manner, please provide all of the information below. If we have any questions or require additional information, we will contact you directly. Please do not submit another request unless it’s been more than 48 business hours from your initial request.

Patient First Name *

Patient Last Name *

Date of Birth * +

Daytime Phone Number *

Treating Physician *

Medication to be Prescribed/Refilled *

Pharmacy Name *

Pharmacy Phone Number *

Email Address *

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