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At LMG Family Practice, we do everything we can to make it easy to take your prescribed medication. Kindly allow our staff three business days to process your prescription refill request. If your refill request is urgent, please call our offices directly. Please fill in all information as completely as possible.
Patient Information
First Name
*
Last Name
*
Middle Initial
Date of Birth
*
Return Phone #
*
Email
*
Pregnant
*
Yes
No
Not Applicable
Nursing
*
Yes
No
Not Applicable
Prescription to be faxed to
*
Pharmacy
Insurance
Both
Pharmacy Name
*
Pharmacy Fax
*
Pharmacy Phone
*
Insurance Name
*
Insurance Fax
*
Insurance Phone
*
Prescribing Provider
*
Charles B. Kish, D.O.
Morris J. Kliger, D.O.
Linda A. Nadwodny, D.O.
Jeffrey H. Portner, M.D.
Sharon Gomez, C.R.N.P.
Rachel Spoonhower, P.A.-C
Prescription Information
Drug Name
*
Drug Dosage (mg)
*
Drug Quantity
*
Pharmacy Name
*
Pharmacy Phone
*
Additional Comments
HOME
WHY LMG?
WHO WE ARE
SERVICES
CONTACT
CONTACT US
LANSDALE LOCATION
BLUE BELL LOCATION
CHALFONT LOCATION
Patient Forms
Bill Payment
Patient Portal