PRESCRIPTIONS & REFILLS
* Denotes Required Fields
* First Name
* Last Name
* Phone Number
* Street Address
* City
* State
* Zip Code
* Email Address
* Email Address Confirmation
PRESCRIPTIONS: Please list the medication you are requesting & dosages in the spaces provided below:
* Prescribing Physician
Prescription 1 / Dosage
Prescription 2 / Dosage
Prescription 3 / Dosage
Prescription 4 / Dosage
Prescription 5 / Dosage
Delivery Method: Select one option below:
Pick-Up at Office
Phone into Pharmacy (if so, include telephone number below)
Pharmacy Phone Number
Faxed to you
Fax Number
Mailed to you (if so, include address below)
Mailing Address
Mailing City
Mailing State
Mailing Zip Code
General Comments
(optional)


To ensure quality medical management, it is RCBM policy that treatment plans are reviewed on a regular basis.  For this reason, there will be a $5 fee per prescription order for patients who have not been seen within the previous 4-month period. This fee will be added to your monthly billing statement.