Medication Refill Request | Connections Wellness Group

Please fill in all areas of the form to submit a request for a medication refill.

Please note that refill requests may take up to 3 business days to be completed.

If you need further assistance or have any questions regarding your medication refill request,
please reach out to us by calling 940.360.4245.

Medication Refill Request

Patient's Name(Required)

First Last

Patient Date of Birth(Required)

Patient Phone Number(Required)

Prescribing Practitioner's Name(Required)

Preferred Pharmacy(Required)

Pharmacy Phone(Required)

Medication Name(Required)

Medication Dosage(Required)

Additional Medication Name

Additional Medication Dosage

Additional Medication Name

Additional Medication Dosage

Additional Medication Name

Additional Medication Dosage

Additional Medication Name

Additional Medication Dosage

Additional Comments

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Connections Wellness Group

We offer a new, refreshing approach to an all-inclusive practice designed to connect you back to what matters most to you.