Secure Form

Prescription Refill Requests

Patients from The CORE Institute® can make prescription refill requests by calling our office at (623) 537-5600 or by completing this secure form below. Please note that all online refill requests take 48-72 hours to process within receipt on regular business days.

The following form uses Secure Sockets Layer (SSL) encryption -- your information is safe with us and will not be used for any purpose that is not CORE-related. Please fill it out as completely as possible. We look forward to serving you.

First Name: *
Last Name: *
Date of Birth: *
/ /
MM/DD/YYYY
Phone: *
Doctor's Name: *
Last Office Visit: *
Pharmacy Name: *
Pharmacy Phone: *
Date of Last Refill: *
/ /
MM/DD/YYYY
Drug Name & Strength: *
Quantity: *
 

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