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DATE METHOD OF SENDING FAX E-MAIL PATIENT INFORMATION Child Name Child Date of Birth Name of Parent/Guardian Relationship Home Phone Number Cell Phone Nymber PRESCRIPTION DETAILS MEDICATION NAME STRENGTH HOW CHILD TAKES MEDICATION Number of days supply ie 10 30 60 90 other Additional Comments LOGISTICS How would you like to get this Pick up at Annapolis Pediatrics location Faxed to pharmacy NAME PHONE. Prescription Refill Request Form This form can be printed and faxed to the pharmacy hotline at 410. 263. 7111. You can also download the form and email to rx annapolispediatrics. com* Please allow us 72 hours to complete the requests. We will contact you if the request will take longer than 72 hours. Please send in one form for each child. Prescription Refill Request Form This form can be printed and faxed to the pharmacy hotline at 410. 263. 7111. You can also download the form and email to rx annapolispediatrics. com* Please allow us 72 hours to complete the requests. 263. 7111. You can also download the form and email to rx annapolispediatrics. com* Please allow us 72 hours to complete the requests. We will contact you if the request will take longer than 72 hours. Please send in one form for each child. Prescription Refill Request Form This form can be printed and faxed to the pharmacy hotline at 410. 263. 7111. You can also download the form and email to rx annapolispediatrics. com* Please allow us 72 hours to complete the requests. We will contact you if the request will take longer than 72 hours. Please send in one form for each child.

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