iHealth Clinics - Imaging & Diagnostics

Patient Information

Patient Full Name*

Date of Birth*

Phone*

Pharmacy Information

Pharmacy Name*

Pharmacy Phone*

Pharmacy Address

Medications

Medication #1

Medication Name *

Dosage *

Quantity *

Additional Notes

Please allow 24-48 hours for your refill request to be processed and sent to your pharmacy. If you are out of medication and need an urgent refill, please call our office directly. Some medications may require a current office visit before a refill can be authorized.

Pharmacy Refill Portal

Patient Information

Pharmacy Information

Medications