Prescription Refill System

Required fields are indicated in bold.

1. Select your Office

2. Select a Pharmacy

Please look through our list of confirmed pharmacies before entering your personal pharmacy. Doing this will help us ensure accuracy and timeliness when calling in your prescriptions.

Select a pharmacy from our list

Or enter a new pharmacy...

New Pharmacy Name Pharmacy Phone Cross Streets
(For example, Furys Ferry/Evans-To-Locks) Address City State Zip Code

3. Describe Your Prescription

Patient Name Patient Date of Birth

Your Email Your Phone
(We may need to call you if we cannot refill your prescription) Medication Name Medication Dosage/Amount
(From label. Example: 200mg twice a day, for 30 days)

4. Agree to Our Terms of Use

This prescription refill system is designed to be used by existing patients of Covenant Pediatrics who have a current prescription that needs to be refilled. Use of this system by persons who are not currently patients of Covenant Pediatrics, who do not have a current prescription through us, or have let their prescription lapse should call into the office to request a refill. We will verify all refill requests before submitting them to the pharmacy of your choice. We reserve the right to deny any refill requests.

I agree to the terms of use above.