Miller Drug | Refill



	Refill Request Instructions: Please Enter the Required Information (denoted by *). Input Rx Number, Drug Name, or OTC item in Item Name / Description Field then Click Add. Your Item should appear in the box directly below. Repeat the process for additional requests. Add additional comments if needed then click Submit Request. Miller Drug 11101 Surrey Hills Blvd. Yukon, OK 73099 405.373.1717

*Denotes Required Fields
Patient Information
*First Name:
*Last Name:
*Address:
City:
State/Province:
Zip:
Contact Information
*Email:
*Phone:	- Please enter a number you can be reached at during business hours -
Prescription / OTC Information
*Item Name or Description:	(example: Rx Number, Drug Name, or OTC Item)
Additional Comments:

*PLEASE NOTE: We consider this information confidential. For this reason, we will be unable to contact anyone other than you concerning this request. We will not under any circumstance leave messages on the answering machine regarding this request.

FAMILY SERVICE | CUTTING EDGE TECHNOLOGY