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Prescription Refill Request Form

Prescription bottle and pills

Cannot afford your medications?

Find out how you can get assistance

  • Over the Counter Medications available for purchase

Please give 24 hours notice for refills.
No refills between 1:00pm and 2:00pm.

Please provide the following information necessary to process birth control refills at the TSU Pharmacy. Please allow one working day for processing your order(s). If there are problems regarding the refill(s) we will try to contact you by phone.

To protect the confidentiality of the client regarding personal information, such as the Social Security number, all data requested is sent directly to the pharmacy and will be accessed only by authorized personnel of the Student Health Center Pharmacy.

Please Note:
In order to verify the identity of the individual picking up the prescription, you will be require to present your ID, at the front desk of the Student Health Center.

Fields marked * are required for submission.

Please enter your name exactly as it appears on school records.

Please use this format: 555-555-5555

This form is in adherence with the Tarleton Privacy Policy, as specified on the University Web Guidelines.