Request Refill

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Please complete the following information to request a refill on a current medication for your child. Requests will be responded to within 24 business hours. Medication must be an existing medication written by a provider at TLC Pediatrics. (*Please note, some medications require an appointment prior to a refill being given. You will be contacted if your child requires an appointment)

If you would like to request an electronic copy of your medical record, click here.

Child's Name *

Child's Date of Birth *

Primary Phone *

Cell Phone *

Email Address *

Name of Medication *

Strength/Dosing Information *

Pharmacy Name *

Pharmacy Address/Location *

Pharmacy Phone # *