University of Southern California

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Prescription Request Form

To request a refill, please enter your information below and press the "Send Refill Request" button. If your browser does not support forms, or if you prefer to request a prescription by phone, please call our USC Internal Medicine Call Center at(323) 442-5100.

(So that we can contact you for confirmation, fields marked with an * are required)

Contact Information
*Is this your first time with us? Yes No
*Is prior authorization required
before this refill can be processed? 		Yes No
*First Name:
Middle Initial:
*Last Name:
*Telephone: - -
*E-mail Address:
*Date of Birth (mm/dd/yyyy):
Pharmacy Information
Pharmacy location where you would prefer your prescription sent:
*Pharmacy phone number: - -
Name of Your Physician:
This is a: New Medication
Refill
*Name of Medication:
Prescription Number (if known):
Dosage/Quantity Needed:
Please List Any Allergies Below:
Enter any message for your physician:
Comments or Questions: