Using your current prescription bottles, please provide us with the information requested below to place a refill request.

This form is only for patients that use Palms Medical Group pharmacies.
If you use an outside pharmacy, please contact that pharmacy directly regarding refills. If you need to fill a new prescription please contact one of our pharmacy locations.

1. Who is this prescription for?

Please provide this information in case the pharmacist needs to contact you.

Please fill in the prescription holder's name
Please enter your phone number with area code (xxx-xxx-xxxx)
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2. Prescription Refill Information

Enter the Palms Medical prescription RX numbers from your medication container.

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3. Pick Up or Mail Order

Pick Up: Please allow 1 business day for prescription processing.
Mail Order: Please allow 3-5 business days for delivery.

Please Choose One
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1830 North Main Street, Bell, FL 32619 | 352-463-0400 | F: 352-463-9062 | Get Directions >>
103 U.S. 27, Branford, FL 32008 | 386-935-0542 | F: 386-935-0598 | Get Directions >>
4784 US Highway 90 West, Lake City, FL 32055 | 386-269-9260 | F: 386-406-6714 | Get Directions >>
911 South Main Street, Trenton, FL 32693 | 352-463-4511 | F: 352-463-4521 | Get Directions >>

200 Southwest 62nd Boulevard, 32607 Gainesville, Florida | 352-664-2266 | F: 352-373-7594 | Get Directions >>

NOTE: Your mail order prescription may ship from any of our pharmacy locations.
Please fill in your mailing address with city, state and zip
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Palms Medical Group is a FTCA Deemed Facility.
This institution is an equal opportunity provider and employer.
This health center receives HHS funding and has Federal Public Health Service (PHS) deemed status with respect to certain health or health-related claims, including medical malpractice claims, for itself and its covered individuals.

This health center is a Health Center Program grantee under 42 U.S.C. 254b, and a deemed Public Health Service employee under 42 U.S.C. 233(g)-(n). uses webforms on this site. These forms require users to give contact information. Contact information from the registration form is used only to send material relating to the event for which it was collected and will not be sold to another party. Palms Medical Group will not disclose, without your consent, personal information collected about you, except for certain explicit circumstances in which disclosure is required by law. Palms Medical Group will not distribute or sell personal information to third-party organizations.
Notice of Privacy Practices | Patient Bill of Rights