Refill a Prescription

To request a prescription refill, complete the following form. Items displayed like this are required.

Please be sure to include a valid e-mail address! Also, please be sure that the address you provide will be able to receive mail from prescriptions@kidslinkohio.com, and that mail from that address will not be blocked by a junk mail filter.

E-mail Address:
Child's Name:
Child's Date of Birth:
Medication:
Dose:	mg
Times per day:	AM PM AM & PM Midday AM, PM & midday
Pharmacy phone number:	If omitted, or if the medication is a controlled substance, your prescription will be mailed.
Additional Information:

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