Dupont Circle Physicians Group

 1737 20th Street, NW  Washington, DC 20009
 p: 202-745-0201   f: 202-332-2794
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Prescription Refills

Local Pharmacies

This service requires all of the following information.

If you do not have the information required,
contact your pharmacy and they will fax the request for you.

Refill request for antibiotics require a consultation with the doctor.

Please indicate if your insurance allows a 90 day supply in the comments field. 

Request will be filled in 24-48 hours




 


 

Patient Name:
DOB:
Patient Phone Number:
Patient Email:
Prescribing Doctor:
Pharmacy Name:
Pharmacy Phone Number:
Pharmacy Fax Number:
Pharmacy Address:
Medication:
Dose:
Comments:
Medication:
Dose:
Comments:
Medication:
Dose:  
Comments: