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Prescription Refill Form


  • By completing this form you are requesting Pharmacy Place refill the prescriptions included and you will not pick them up prior to the time indicated.
  • Select the date and time of day (morning or afternoon) you would like to pick up your order. Please note that Pharmacy Place is closed Sunday and holidays. Morning requests will be available by 9am and afternoon requests can be picked up after 1pm.
  • Complete all information on the form so we may best serve you.
  • Completion of all requests is subject to availability of refills on any prescription ordered and the approval of your insurance company.
  • If there have been any changes to your insurance, please add that information in the comment box. Insurance changes may result in delays at pickup due to rebilling of claims.
  • Add comments if there have been any changes to your medical condition (i.e. new allergies, dosage changes, medication side effects, etc.)
  • To ensure your order will be filled in its entirety, please allow two days for processing. Any delays beyond that will be communicated by phone or email.
  • You may request up to ten (10) prescriptions on one Request Form. Please enter the PRESCRIPTION NUMBER (not name) in the form below. Please submit an additional form for more prescriptions.


  • Port Huron Hospital Pharmacy Place
  • Yale Community Health Center Pharmacy Place

Enter Prescriptions Numbers for items to be refilled below.


   Calendar (Click image to select pickup date.
Note:  Pharmacy Place is closed Sundays and holidays)

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