UHS Pharmacy Online Prescription Refills

Information on this form is kept confidential by the pharmacy staff. However, it is sent via email, and there are limits to the absolute security of email. If you prefer, you may order prescription refills by phone: 608-263-4990.

Need to transfer a prescription to UHS? Download this form and fill in the information about your prescriptions. Send it to the pharmacy via fax (608-265-8714) or email (send the form as an attachment, and put "University Health Services" in the subject line). Allow one business day before picking up your prescription.

Please fill in the required fields (marked with *)


Name:
 *
UW Student ID Number:
 *
Telephone #1:
(in case we have questions about your refill)
 *
Telephone #2:
  

Email:
 *

Prescription Number:
[highlighted in yellow on your prescription label, and ends with "03"]
example: 9876543-03

*
Additional Prescriptions:
 

 

 

 

Bill your insurance plan?
[if we have an insurance plan on file for you, we can automatically direct the claim to them]

 
 YES    NO 

When would you like to pick up your prescription? Please give us one business day in advance.
Today is: Wednesday, June 19, 2013
Pharmacy hours:
Mon | Tue | Thu | Fri �� 8:30 am to 5 pm
Wed �� 9 am to 5 pm

  
Date Time

Message:
What quantity refill would you like?
example: if you are ordering birth control,
how many months do you want?

Any other comments?

 
Enter text (not case sensitive):