5969 E Broad St. Columbus, OH 43213-1546
Phone (614) 864-6010
Toll Free (866) 877-1757
Fax (614)
864-0306
Prescription Refill Request
Please complete all of the following fields to ensure that your prescription
refill request is complete.
THIS EMAIL RX
FORM WAS CREATED TO REDUCE THE NUMBER OF INCOMING PHONE CALLS SO THAT WE
CAN BETTER SERVE OUR PATIENTS. PLEASE DO NOT CALL TO SEE IF THE
EMAIL WENT THROUGH.
Please note: We
will be happy to mail prescriptions to patients, but due to the high
cost of postage, please send a self-addressed and stamped envelope.
* NEW - LOOKING FOR A WAY TO SAVE MONEY ON YOUR PRESCRIPTIONS?
To assist with getting your medications in a fast, convenient, and
affordable way, we are now offering you the option of receiving the
medication at our office, just seconds after receiving your
prescription. You may still choose to get your prescriptions at a
pharmacy. However with this option, you will start saving
immediately and avoid waiting for your prescriptions at the pharmacy.
Ask your physician for details.
Physician name
Patient Name
Patient Email Address
Date of Birth
,
Drug Name
Drug
Strength
Quantity
How many times is the drug taken per day?
Number of refills
Pharmacy or Mail Order Name
Pharmacy Phone
How do you want the RX filled?
Prescription
Refills - Our policy is to complete prescription refill requests within 48 hours
of your request. All mail order prescriptions will be available for pickup at
the office within 48 hours. Local prescription refills will be faxed/called to
your pharmacy within 48 hours. If you live a far distance away or are physically
unable to pick the prescription up, we can mail the prescription to you.
Canyon Medical Center
J. Kelley Brennan, M.D. Stephen Canowitz, M.D.
John DiPietra, M.D. Mark Hackman, M.D. Robert Hershfield, M.D.
Sarah Jonaus, M.D. Stephen Shell, M.D. Ethan Shoaps, M.D. Boris
Valdman, M.D. Timothy Nuss, C.N.P.
Susan Rankin, C.N.P.
Office Hours:
Monday : 8am to 5pm
Tuesday: 8am to 5pm
Wednesday: 8am to 5pm
Thursday: 8am to 5pm
Friday: 8am to 5pm We offer appointments during the times listed above.
Laboratory Hours:
Monday: 7am to 4:30pm
Tuesday: 7am to 4:30pm
Wednesday: 7am to 4:30pm
Thursday: 7am to 4:30pm
Friday: 7am to 4:30pm The Laboratory is first come,
first serve.
Prescription
Refills - Our policy is to complete prescription refill requests within 48 hours
of your request. All mail order prescriptions will be available for pickup at
the office within 48 hours. Local prescription refills will be faxed/called to
your pharmacy within 48 hours. If you live a far distance away or are physically
unable to pick the prescription up, we can mail the prescription to you.
