Prescription Refill Reminder Form

* First Name:	* Last Name:
* Date of Birth -- month -- January February March April May June July August September October November December	* E-mail Address:
* Phone:	Cell:
* Frequency Weekly Bi-Weekly Monthly 2 Months 3 Months	* Start Date -- month -- January February March April May June July August September October November December

* 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.