Medication Refill/Query Form

 Clinic try to make sure that all patients have enough supply of medications until their next scheduled appointment. If you already missed your appointment or you need to reschedule it, please call us or make appointment online. Please fill all sections below and then click on Submit button at bottom. If there any issues then please use Laptop or Computer. You also can try to use Google Chrome browser on smartphone if needed. If you do not get any response within 24 hours (for weekends and holidays it may take up to 72 hours) then please send the request again or email us at info@piedmontbs.com

Authorization *

I have read the instructions above and I authorize to do Medication Refill Request via Online. It can take time (hours to days) to get process for the pharmacy to receive it.

Patient Name *

First

Last

Patient DOB *

Phone *

Patient Email *

Person Requesting (If Applicable example Legal Guardian) *

Medication Names ( Including mg and frequency) *

Website

Submit