Burlington Family Practice
Scheduling An Appointment? 1041 Kirkpatrick Rd., Suite 200, Burlington, NC 27215 | Call 336-584-3100 | Fax 336-584-0696 Home
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Refill Request | Needing A Prescription Refill?
If you feel you need a new medication or a prescription for an acute illness, you will probably need to be seen in our office first. Before requesting refills for chronic medications, please make sure you are not due for a follow up visit with your healthcare provider. If you need your prescription refilled before you can get an appointment, contact your pharmacist and ask them to send a refill request to our office. Your prescription will be filled much quicker and will be filled accurately if your pharmacist contacts our office directly.

If your pharmacist is not able to send a refill request to our office, please submit the following form. If your healthcare provider approves your request, it will be filled within 48 hours of its submission. If we are not able to refill the prescription, we will call you at the contact number you provide below.

Patient Name: *
Email:
Phone:
Date of Birth:
Pharmacy Name:
Physician:
Medication Name:
Medication Dosage:
Medication Frequency:
Medication Description:
 
  Enter the text as shown in the image below: