Company Name - Company Message
Prescription Refill Request
Last name
First name
Date of birth
Phone number:
Prescription information (name of the medicine, dosage, how you take it etc):
Pharmacy name
Pharmacy phone number
Additional information:
Khan Pediatrics is fully HIPPA-compliant, as federal law requires. Your information will be submitted directly to our clinical staff only. If you have any concerns, please email the webmaster at