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:*  

* required field