Please enable JavaScript in your browser to complete this form.Medication RefillPatient Name *FirstLastDate of Birth *Contact Number *If we run into issues, we will contact you at this number for more details.Provider NameI don't knowDr. Dipen Patel, MDDr. Jayesh Patel, MDCrystal Bales FNP-CName of Medication & Dosage (Example: Advil 30mg) *Please be as detailed as possible, and recheck the medication name.Days Supply (Example 90-days) *Number of tablets? Your Pharmacy AddressAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeIf no pharmacy is specified, your default Pharmacy in our system will get the refill.Submit