Online Refills - Dr. John Laura

Refill Request

Date of Birth*

Would you like a physician to contact you regarding ongoing symptoms?

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Prescription(s)*
Please include as much information as possible, including: Rx number, name of medication & strength:

Please list any known allergies you have:

Please provide your pharmacy information for pick-up:

If you need something else, not listed above, please specify what in the space provided and we will get back to you:

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