Student Health Center - Prescription Refill Request
Name
Student number
Date of Birth
Daytime phone number
E-mail Address
Medication Request
Medication Name
Dose
Quantity
Refills
Medication Request
Medication Name
Dose
Quantity
Refills
Medication Request
Medication Name
Dose
Quantity
Refills
Birth Control Request
Name of birth control medication
How many months needed?
Allergies
Do you have medication allergies? (Yes
/ No
)
If Yes, please list allergies:
Pharmacy or pick up script option
(Yes
/ No
)
I will need to pick up written scrript at SHC registration desk.
(Yes
/ No
) UPMB/SHC pharmacy
Other pharmacy name
Pharmacy phone number
Additional Comments
: