Prescription Refill Policy

Dr. Khan wants her patients to come in for a scheduled appointment prior to any of their medications running out.

In the event something unforeseen happens, please schedule an appointment first and then fill out and call or email in the information requested below.

  1. Patient’s Name
  2. Patient’s Date of Birth
  3. Date of Next Appointment
  4. Pharmacy Name, Location & Telephone Number
  5. Name of the medication to be refilled
  6. Dosage of the refill medication (how the medication is taken and dosage amount)
  7. How much of the medication remains

Refills will not be prescribed unless all the information above is provided to our office.

You may also send your request via the form below. After submitting your information, please contact our office to confirm receipt of your refill request.

BY SUBMITTING THIS FORM, YOU HAVE MY CONSENT TO COMMUNICATE VIA EMAIL. I RECOGNIZE THAT EMAIL IS NOT A SECURE FORM OF COMMUNICATION AND THERE IS SOME RISK THAT ANY PROTECTED HEALTH INFORMATION THAT MAY BE CONTAINED IN SUCH EMAIL MAY BE DISCLOSED TO, OR INTERCEPTED BY UNAUTHORIZED THIRD PARTIES. USE OF EMAIL TO COMMUNICATE PROTECTED HEALTH INFORMATION TO SALMA KHAN, M.D. INDICATES THAT I ACKNOWLEDGE AND ACCEPT THE POSSIBLE RISKS ASSOCIATED WITH SUCH COMMUNICATION.

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