A Woman's View Email Center

Prescription Refills

Please complete the following form and then click the Submit button at the bottom of the page.  This email is checked about two times per day, once in the morning and once during the middle of the day.  Any request for prescription refills sent via email after 4:00 pm will be processed the next business day.  The fields marked with an asterisk(*) are required.  Our email forms are currently not working due to a problem with our server.  Please use your normal email program to submit all the requested information to awvnurse@charter.net. 

NOTE: You may want to call the pharmacy prior to going to pick up your prescription.  If they say they have not received it, call Ashley West, RN BSN at (828) 345-6310.  Keep in mind that occasionally it is the pharmacy that forgets to check their messages of fax machine, but we will be happy to follow up for you.  Thank you.

  1. Please provide the following contact information:

    Full Name*  
    Daytime Phone*  
    Home Phone
    E-mail  

  2. In order that we may properly identify you, please provide us with the following information:

    Date of Birth (dd/mm/yyyy)*  

  3. Who is your current health care provider?*

     

  4. What is the name of your pharmacy?*

  5. Where is your pharmacy located?*

  6. If possible, provide the telephone number for your pharmacy:

  7. What is the medication and dosage that you need refilled? (Use label from old prescription.)*

     

  8. Please provide us with any other information that you feel we may need to process this request.

    **Note:  This email is not sent encrypted and as such is not covered by our privacy policy.  Please type "yes" here to verify that you understand that you acknowledge that you are aware of potential loss of privacy and accept responsibility for this communication.  (This email cannot be sent without this acknowledgment.)

* Required Field

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Revised: June 02, 2008