Harris Family Medical Center

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HFMC Pharmacy Orders

Please complete this form and submit 24 hours prior to planned pick-up. For urgent orders, please call in order to (321) 726-1614.

If you do not need a refill, but have a question or comment for the pharmacy, call or e-mail us.

If you need a refill, please make sure that your bottle indicates refills remaining, otherwise, please contact your physician for authorization for a refill.

HFMC Pharmacy Refill Form
*Required Fields are in Red.
What is your full name?	*
What is the best phone number during business hours to reach you?	*
What is the best e-mail to reach you?	*
What is the patient's full name?	*
What is the patient's date of birth?	*
Enter the name and strength OR prescription number of the item to be filled for above patient:	*
Enter the name and strength OR prescription number of the item to be filled for above patient:
Enter the name and strength OR prescription number of the item to be filled for above patient:
Enter the name and strength OR prescription number of the item to be filled for above patient:
Please enter any special concerns or requests:
Indicate here the date/time you plan on picking up this order or if it is to be delivered to Palm Bay.	*

Be aware that e-mail may generally not provide the same level of confidentiality as telephone or U.S. mail communications. Your e-mails will be printed out by HFMC staff, attached to your chart, and placed on the desk of the person to whom they are directed. Generally, this aspect of the communications is secure from outside eyes, but diversion could occur via the ISP or through e-mail monitoring by network supervisors, so keep that in mind anytime you send anyone an e-mail.