Prescription Refill Request Form - Terms & Conditions Apply

This prescription refill request form is for existing active patients of Greeg Family Healthcare Clinic.

Please feel free to call us directly at (575) 532-5700 if you happen to have any questions regarding this form.

HOW THIS WORKS

If you have been seen within the past 3 months, and wish to submit a Prescription Refill Request, you may do so by filling out this form.
Please fill out the form correctly with the correct & accurate information/details.
One of our staff members will review your request within 24 hours and forward it to our medical staff for a final determination.
We will call you to discuss the outcome of your request.
Please note that if it has been more than 3 months since your last visit, we might ask you to first schedule an appointment to come in to be seen at the clinic before we can refill your prescription.
Please also note that refill requests for Controlled Substances will not be processed without a face-to-face contact with our provider.
If you do not receive a call from the clinic within 24 hours of your request, regarding your Prescription Refill Request, please call us directly at (575) 532-5700.
If you are submitting your request after official clinic hours on Friday or sometime over the weekend, please allow until Monday for us to process your request.
If you have an urgent request that cannot wait, please feel free to contact us directly via phone at (575) 532-5700.
Please make sure that you provide us with the correct phone number, where we can call you at, once we have a chance. Please understand that we will only make 4 attempts to call you once we get a chance. Upon our 4th attempt to call you, we will leave a message that we have attempted to contact/call you. We will only hold on to your request for up to 24 hours from our 4th call attempt, and then we will just discard/delete your request. Thereafter, you will either need to call-in your request via phone, or if your request is not for an urgent need...you can re-submit another request online.
WE WILL NOT REPLY TO YOU VIA EMAIL. In compliance with Federal Medical Rules/Laws & Regulations, and as part of our clinic's practice & policies, we will not communicate with you via e-mail. The only email that you can ever get from this system is an e-mail copy of your submitted request online. Please feel free to ask our staff if you have any questions about this on your next visit to our clinic.

Terms Of Use

Only for patients that have recently been seen at Greeg Family Healthcare Clinic within the past 3 months, with active refill prescriptions.
Please note that Controlled substances require a MANDATORY visit to the clinic. This is a Federal LAW Requirement.
Please note that it is the policy of Greeg Family Healthcare to see patients at least once every 3 months in order for a prescription to be refilled. If the patient has been cleared by the medical staff to be allowed to submit their refill request via this form, only those requests will automatically be processed.

Please NOTE:
- Please properly fill out the form completely with accurate and complete information. It is a requirement for us to contact you to validate the request. We will not submit the refill request without someone from our clinic first contacting you to confirm your refill request.
- We will also contact you in the event that we find a problem with your refill request.

None of the information that you submit through this website is saved. In compliance with online Medical Regulations, all information is directly delivered to the clinic and then destroyed/deleted. Record of each transaction is noted in the patient's file/record keeping system. Please contact our clinic if you have any questions regarding this online Prescription Refill Request Form.

If you are a human and are seeing this field, please leave it blank.

Fields marked with a * are required

Who is sending this request?

Understand that this form has 2 parts. The first part, is for our medical staff to understand, who it is that is submitting this request. It is important for us to understand who it is that we need to call back, to validate this request. So please provide us with your name, and a telephone number you could be reached.

Your First & Last Name * Help Text

At What Phone Number Can We Call You? *

Patient Information

This second part is to understand who the patient is for this request. Please provide the patient's Name, Date Of Birth, and below that, please let us know what medication you need the refill for. Please mention if more than one medication refill.

Patient Name - First & Last * Help Text

Patien't Date Of Birth * Help Text

Here, please let us know if the patient will need more than one medication/prescription refill. Please feel free to include the name of the medication. Or any additional information/details that can better help us process your request.

If you are a mother, and this request is for more than one Child/Patient, please include in the text box below, the "Name" and "Date of Birth" of any of the other patients to include in the processing of this request. As well any needed/helpful notes about each patient to help us - help you. Thank You.

Please Provide Any Additional Information Help Text

"IF" you would like an E-Mail Copy of this request, what is your E-Mail Address

Please note, that only IF you would like to receive an email copy of this request, please include your email address below, so that the system, can email you a copy of this request.