Welcome to OSNC's new online Prescription Refill Request Form. You can now request your medications - REFILLS ONLY - from the comfort and convenience of your own computer. Please fill out the following form in its entirety (all fields are required to complete). Please be sure to provide contact information where you can be reached in case there are any questions regarding your request. When you are finished, please click the Send Request button.

You must complete all of the fields below:

Full Name:
Email Address:
Daytime Phone:
Evening Phone:
Date of Birth:
Check One:	I would preferred to be contacted about my prescription via:email or by phone.
In this section you are able to request refills for medications. Simply fill out the required information for your prescription, then click Send Request' to enter your refill requests.
Provider Name:	Dr. Mark Galland Dr. Clifford Wheeless Dr. Paul Suh Dr. Lawrence Yenni Dr. Cary Idler Dr. Derek Watson Dr. Ingrid Luo-Tseng
Medication:
Number of Refills:
Dosage:
Frequency:
Pharmacy:
Pharmacy Phone:
Comments: (optional)
Security Image Verification: Please re-enter the security code shown above: or click for a new security image

Note: Please allow two (2) business days for your refill request to be processed and transmitted to your pharmacy. Be sure to check with your pharmacy to ensure your prescription is ready for pick-up.