Using your current prescription bottles, please provide us with the information requested below to place a refill request.

This form is only for patients that use Palms Medical Group pharmacies.
If you use an outside pharmacy, please contact that pharmacy directly regarding refills. If you need to fill a new prescription please contact one of our pharmacy locations.

1. Who is this prescription for?

Please provide this information in case the pharmacist needs to contact you.

Please fill in the prescription holder's name
Please enter your phone number with area code (xxx-xxx-xxxx)
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2. Prescription Refill Information

Enter the Palms Medical prescription RX numbers from your medication container.

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3. Pick Up or Mail Order

Pick Up: Please allow 1 business day for prescription processing.
Mail Order: Please allow 3-5 business days for delivery.

Please Choose One
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1830 North Main Street, Bell, FL 32619 | 352-463-0400 | F: 352-463-9062 | Get Directions >>
103 U.S. 27, Branford, FL 32008 | 386-935-0542 | F: 386-935-0598 | Get Directions >>
911 South Main Street, Trenton, FL 32693 | 352-463-4511 | F: 352-463-4521 | Get Directions >>
NOTE: Your mail order prescription may ship from any of our pharmacy locations.
Please fill in your mailing address with city, state and zip
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To make an appointment at any location, or to speak with a Financial Services Specialist please call 1-888-730-2374

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This institution is an equal opportunity provider and employer.
Palms Medical Group is a FTCA Deemed Facility.
This health center is a Health Center Program grantee under 42 U.S.C. 254b, and a deemed Public Health Service employee under 42 U.S.C. 233(g)-(n).
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