Canyon Medical Center

Patient Forms On-Line Consent Form On-Line Refill Request

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Canyon Medical Center Prescription Refill Request Form

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.

Office Hours:
Monday-Friday: 8am to 5pm
We offer appointments during the times listed above.

Laboratory Hours:
Monday-Friday: 7am to 4:30pm

List Of Doctors:
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.
Suzette Viola, C.N.P.

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.
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?

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