OHSU Pharmacy Services

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OHSU Outpatient Pharmacy

Prescription Refill Request Form

Please enter the following information:

Use "Tab" key to move to next field

Patient Name:		..	Medical Record #:
Please fill three-month supply
Rx #1:	Rx #2:		Rx #3:
Rx #4:	Rx #5:		Rx #6:
Rx #7:	Rx #8:		Rx #9:
Rx #10:	Rx #11:		Rx #12:

Pick Up	Please Mail	Mailing costs will be charged to a credit card. We will call for your card number. Please allow 2 weekdays for your refill to be prepared.
Day phone:		Other phone:
Address:		Apt # or Other:
City:		State:	Zip:

Refills may be picked up at the Outpatient Pharmacy in the Physicians Pavilion

For questions about your prescription, please call 503-494-7570 during our regular business hours.

Contact us:

Oregon Health & Sciences Univ.
Dept. of Pharmacy Services
Mailcode CR9-4
3181 SW Sam Jackson Park Road
Portland, OR 97239-3098
Phone: 503-494-7570

Fax: 503-494-1023

Last updated 08/17/2006