CNS Medical Group | Request Prescription Refill

Call your pharmacy for all prescription refills, even if the bottle indicates there are no more refills available. The only exception to this rule is for narcotic medications which require a new written prescription each time it is filled.

Use the form below when there has been a change in strength or directions for medications needing to be refilled and to request written prescriptions for narcotics. Indicate if you will pick up written prescriptions or if you want us to mail them.

Patient Name:


Last Name	M.I	First Name

Date of Birth:


Month	Day	Year

Phone:

Email:

Physician:

Pharmacy:

Pharmacy Phone:

Pharmacy Fax:

Existing Prescriptions:

Call pharmacy even if bottle says "no refills".
Pharmacy will contact us for authorization.
Changes since last refill:

Narcotic Refill:

Call (303) 789-8368 Leave name, phone number, and medication request
Mail Rx
Pick Up at CNS

Wound or Urologic Supplies:

Provide Information:

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