top of page

Prescriptions

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 officemanager2@khanpediatrics.com.

bottom of page