Name: Buster Zztest | DOB: 6/15/1953 | MRN: 14331292 | PCP: Patricia G. HINZ MD

Medication Renewal Request

To complete your medication renewal request:
Please review the preferred pharmacy selection before renewing your medication. This is where you will pick up your medication.
To pick up your medication from a different pharmacy, select Other from the preferred pharmacy box. Enter the name, address(street, city,state) and the phone number of the new pharmacy in the comments box and click the Request Rx Renewal button.
Only the medication(s) listed below will be renewed. Do not enter a new medication in the comments box.

1. Select a prescription to renew

AZMACORT AERS 100 MCG/ACT IN
LISINOPRIL TABS 10 MG OR
ALBUTEROL AERS 90 MCG/ACT IN
LIPITOR 20 MG PO TABS

2. Select a pharmacy

If your renewal is approved, the prescription will be sent to this pharmacy. You may send a renewal request without selecting a pharmacy.

3. Enter any additional information regarding this request

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