SIMEDHealth

This form is for prescription refills for the SIMEDHealth Pharmacy only. If you need a refill for another pharmacy, you will need to contact your physician's clinic directly.

Full Name *

i.e. John Smith

E-mail *

(smith@myemail.com)

Phone: *

i.e. 352-123-4567

Alt. Phone

Prescription Number(s) *

Please separate your Prescription Numbers with a ","

Note: (For SIMEDHealth Pharmacy staff. Communications to your physician's office should be made using the Patient Portal.

HIPAA and PHI Disclaimer

I understand that by submitting my request I may be providing Personal Health Information (PHI) to SIMEDHealth and that this PHI may be viewed by employees or staff of SIMEDHealth.

Prescription Refill