Fillable PRESCRIPTION REFILL REQUEST (Native Village of Eyak)

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PRESCRIPTION REFILL REQUEST (Native Village of Eyak)

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Revision: 2.14.2020
Ilanka Community Health Center
705 Second Street – PO Box 2290
Cordova, AK 99574
Ph: 907-424-3622 Fax: 907-424-3275
PRESCRIPTION REFILL REQUEST
Please note there is a 48 hour turn around time on refill request.
This is not confirming a refill will be completed without further conversation from a nurse.
This is a request and you may be asked to schedule an appointment before a refill is
granted.
Patient Name: ___________________________________________________________________________
Patient Contact #: ____________________________________ DOB: _______________________________
Medication Name:
Dosage:
Quantity:
Prescribing Doctor:
Pharmacy:
Patient Signature: ___________________________________________ Date: _______________________
For office use only:
ICHC Signature: _____________________________________________
Scanned into Chart Date: _____________________________________
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PRESCRIPTION REFILL REQUEST (Native Village of Eyak)

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Completed 27 January 2021

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