Online Prescription Refill Form
Current patients may refill their medication by using this online form. Allow at least 2 business days for prescriptions to be called in to your pharmacy or written up for your personal pick up. Please remember that Class II Narcotic prescriptions must be picked up in person by you or by another preauthorized person.
Please do not use this form for urgent matters or early medication refills.
We will only contact you about your refill request if there is a problem. Thank You!
If this is an emergency, dial 911.
PATIENT INFO

Date:    Patient First Name:  Patient Last Name:
Date of Birth: Phone Number:
Alternate Phone Number:   Email (if you want confirmation of refill):
TCPC Pain Physician:   Location:
Any Known Medication Allergies:   If Yes or if OTHER, please describe the allergy below           
                    
What pharmacy?   Phone Number :
 
Use this form in place of a phone call to ask your Doctor/PA/NP non urgent questions, schedule non urgent Follow Up appointments or to provide him/her some feedback or information. Examples of uses of this form include giving them an update of your pain level after a procedure or new developments in your health affecting your pain, asking for help with non-urgent problems, etc. Complex or involved questions are best dealt with by making an appointment and discussing the issues in person with the physician or nurse.
 

No Refill Needed (select this if you just have a question or comment)

MEDICATION REFILL INFO
Please, be accurate on the drug name & dosage, read off of the bottle or package if possible. If you have prescription number, please enter that as well or enter 0 if there is no prescription number. You can use this page to enter up to three different refills,  complete the designated areas and press SUBMIT.
If you would like a printed copy of your refill, press PRINT then press SUBMIT.
After sending your refill you will be brought back to the TCPC Homepage.

 

Medication #1
Drug Name:    Drug size/strength (mg/meq/%):  Rx #: 
Refill Quantity (Total Number of pills):    Number of pills per day taken:  
Number of times per day:
Or describe other specific instructions for this medication:  
Are you tolerating medication? 
Is medication effective?  
Medication #2
Drug Name:    Drug size/strength (mg/meq/%):  Rx #: 
Refill Quantity (Total Number of pills):    Number of pills per day taken:  
Number of times per day:  
Or describe other specific instructions for this medication:  
Are you tolerating medication? 
Is medication effective?  
Medication #3
Drug Name:    Drug size/strength (mg/meq/%):  Rx #: 
Refill Quantity (Total Number of pills):    Number of pills per day taken:  
Number of times per day:   
Or describe other specific instructions for this medication:  
Are you tolerating medication? 
Is medication effective?  

  Please click here to confirm that you have read and agree with the below disclaimers: (required)
Conditions of Online Prescription Refill Form:

Tri-County Pain Consultants values your privacy. We have taken all reasonable precautions to ensure that your information is securely transmitted. This refill form should be used for routine purposes only, if this is an early or urgent refill, call the refill line and leave a message for the nurse to contact you back. Refill phone numbers:

  • All locations (248) 735-9815

These forms are downloaded on a daily basis Monday - Friday. You can expect your prescriptions to be ready within two business days of the form being submitted.

This form is for medication refills, general non urgent questions about your treatment or schedule non urgent follow up appointements. To schedule an urgent follow up appointment you will need to call the location you are seen at to have these issues addressed.

  • Livonia (734) 953-7110
  • Novi (248) 735-8272
  • Royal Oak (248) 435-4328