Refill Request Form

Legal First Name:

Legal Last Name:

Date of Birth:

Email:

I wish to refill the following prescriptions (Check all that apply):

My current birth control prescription. My current emergency contraception prescription. My current external (male) condom prescription. My current internal (female) condom prescription.

How would you like to receive your prescription? (Check only one):

I will pick up my prescription at the Superior clinic. (You will receive an email confirmation when your prescription is ready to be picked up.) I would like my prescription mailed to my address on file.

By submitting this form I agree to receive email communication from Health Care Clinic and deny any questions or concerns regarding my requested prescription.

Superior, WI Location

Ashland, WI Location

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