Sharon Regional Health System Prescription Refill Request Form

Welcome to Sharon Regional Health System's new secure online Prescription Refill Request Form. You can now request your medications from the comfort and convenience of your own computer.

Please fill out the following form in its entirety (all fields are required to complete). When you are finished, please click the "Submit Request" button. Within minutes you will receive a confirmation email. This will signify that our office has received your request, and it will be processed, and sent to the pharmacy that you have specified within 48 hours. Once your request has been submitted to the specified pharmacy, you will receive an e-mail which will let you know your script is ready for pick up. We will contact you by phone if there is additional information needed to complete your request.

• Your Name:
• Phone Number:
• Social Security Number:
• Email Address:
• Birth Date:
• Department:

  select

  • -- Select a department --
  • Cardiology
  • Cardiothoracic Surgical Specialist
  • Center for Digestive Disease
  • Ear , Nose , Throat & Allergy
  • Endocrinology
  • Family Practice
  • General Surgerical Specialist
  • Obstetrics/ Gynecology
  • Orthopedic Center
  • Pain Management
  • Pulmonology Specialist
• Physician:

  select
• Requested Medication:
• New PrescriptionRefill
• Dosage:
• Frequency:
• Pharmacy:
• Phone Number:
• Comments: