Welcome to OSNC's new online Prescription Refill Request Form. You can now request your medications - REFILLS ONLY - from the comfort and convenience of your own computer.

Please fill out the following form in its entirety (all fields are required to complete). Please be sure to provide contact information where you can be reached in case there are any questions regarding your request. When you are finished, please click the Send Request button.

You must complete all of the fields below:

Patient Information

Full Name: *

Email Address: *

Daytime Phone: *

Evening Phone: *

Date of Birth: *

MonthJanFebMarAprMayJunJulAugSepOctNovDec

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I would preferred to be contacted about my prescription via: *

Email

Phone

Medication Information

In this section you are able to request refills for medications. Simply fill out the required information for your prescription, then click Send Request' to enter your refill requests.

Provider Name: * select...Dr. Mark GallandDr. Clifford WheelessDr. Paul SuhDr. Lawrence YenniDr. Cary IdlerDr. Derek WatsonDr. Ingrid Luo-Tseng

Name of Medication: *

Number of Refills: *

Dosage: *

Frequency: *

Pharmacy: *

Pharmacy Phone: *

Please include area code.

Comments (optional):

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