Prescription Refill Request

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Please only fill out this form if:

- You are an existing patient of Honolulu Dermatology. New patients please schedule through website.

- You have seen Dr. Gill within the last year. If your last visit with Dr. Gill was more than one year ago, please schedule a follow-up appointment through the website.

Note: In-office dispensed prescriptions (little white topical prescription bottles) will not be shipped unless a Hawaii address is filled out below.

Please fill out a separate form for each requested refill.

Patient name (First Last): *

Patient date of birth: *

YYYY

Prescription requested to be refilled: *

How would you describe the condition that the prescription is addressing: *

Getting Worse

Staying the Same

Getting Better

Completely Resolved

Other:

Describe any side effects you are having. If none, type "none" *

Does it seem the dosage/frequency is working well for you? *

Yes

No, I think dosage/frequency may need to be lowered

No, I think dosage/frequency may need to be increased

Other:

Please specify refill location or shipment. *

Please send refills to same pharmacy as previously used.

Please send refills to new pharmacy, new pharmacy address is provided below. (Note: we only send to Hawaii pharmacies)

My prescription was dispensed from Honolulu Dermatology's office, I would like to have prescriptions shipped for $8 plus tax (Please specify shipping address below)

My prescription was dispensed from Honolulu Dermatology's office, I would like office to contact me to arrange pick-up during business hours.

Please provide name & address of new pharmacy or your shipping address (if applicable):

Is there anything else we should know?

Refill requests are normally filled within 24 hours. Would you like to be notified when the prescription has been approved by Dr. Gill and sent to the pharmacy? *

Yes, via text to phone number on file (message and data rates may apply)

Yes, via email to email address on file

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