Prescription Renewal Form
Please complete the secure form below and press submit. If you have more than three prescriptions refills, please complete this form again. If there is a problem with your prescription refill request or we require more information from you, we will contact you by phone.

All requests will be processed within 24 - 48 hours during regular business hours, Monday - Friday, 9:00 am - 5:00 pm, excluding holidays. If you require an immediate refill or have a question, please contact our office.


Name:*
Phone:*
Fax:
E-Mail:
Date of Birth:

Allergies:

Would you like to have your prescription:


Prescription 1:

Medication:*
Dosage:*
Frequency:

Prescription 2:

Medication:*
Dosage:*
Frequency:

Prescription 3:

Medication:*
Dosage:*
Frequency:

Pharmacy Information:

Pharmacy Name:*
Pharmacy Location:*
Pharmacy Phone:
Comments:*





Jim W. Turnage, MD, PsyD Holistic Family Physician                                                         7930 Frost Street, Suite 103   San Diego, CA 92123                 Phone: 858.569.6800   Fax: 858.569.6807