1400 E Golf Road
Suite 118
Des Plaines, IL 60016
ph: 847-635-2001
fax: 847-635-2076
kmpclini
Refills Request Form
This page is meant for established KMP patients only, both in the clinic and on home visits.
To our patients, please try to make your refill request 2 (two) weeks before you run out of medication refills.
Please read this before you fill up the request form !!!
Due to HIPPA regulations please identify the patients name with the medical record number we assigned you.
The company is the name of the pharmacy.
The phone slot is for the phone number of the pharmacy.
The question and comment slot is for the medications and dosage you are requesting for.
This aboveinstructions have to be complied strictly, for us to refill your medications properly, securely & safely.
1400 E Golf Road
Suite 118
Des Plaines, IL 60016
ph: 847-635-2001
fax: 847-635-2076
kmpclini
