Prescription Refill Requests

To order refills online, complete the following form. You will need your prescription number, which can be found on your original order’s packing slip or on your prescription label.

This form is only for existing prescriptions filled by Creekmore Clinic. If your existing prescription indicates it was filled by another clinic or pharmacy, please call the phone number listed on your prescription.

    Your Full Name:

    Your Email:

    Your Phone:

    Your Address:



    Zip Code:

    Pharmacy Name:

    Drug Name:


    Prescribing Physician: