Prescription Refill Reminder Form

First Name:
Last Name:
Date of Birth
  
E-mail Address:
Phone:
Cell:
Frequency
 
Start Date
  

* Please note that this is a courtesy service, and that Dauphin Clinic Pharmacy won't be liable if the delivery of the email reminder is delayed, or if it does not deliver at all, as sometimes recipient mail servers temporarily delay or block messages, or other technical issues could arise prohibiting the delivery of any messages.