Prescription Refill Form

Medications will be called into the pharmacy on the next business day for pickup. If you require your prescription sooner, please call the office at 207-524-3501.

Disclaimer: This website is for refills of existing medications prescribed by a DFD Clinician only. New prescriptions or prescriptions from other doctors will not be filled through this site.

Patient Information:

Name:*

First		Last

Date of Birth:*

Address*

Line 1

Line 2

City, state, zip

, ,

Telephone:*

Cell phone:
(optional)

Medication Information:

Medication Name:*

Dose:*

Prescribing Physician:*

Desired Pharmacy:*

view contact information

Don't see your pharmacy? Type it in the box below. Please provide as complete an address as possible.

* required field