You may use this page to request repeat regular prescriptions.  

Please do not request medications that are not on your regular script. If you are a new patient and have not previously been given your regular medication by Carefirst you must be seen first. The final decision on types and amounts of medications supplied on repeat prescription is up to your Doctor. You may be asked to attend for a consultation before receiving your medications.

Either complete the form and click the Submit button or Print the page and post, fax or drop it in to Carefirst.

Please ensure to supply complete information on medication name and dosage. If there is insufficient information we can not proceed.

Please allow at least 24 hours for your request to be processed.

Patient Name       Date of Birth 

Prescription to be picked up:           Faxed:      If Faxed, Name of Pharmacy:

Example:

Medication      Betaloc                            Dose / Frequency     47.5mg tab twice daily                 Amount    3 mths

Medication    Dose / Frequency    Amount 

Medication    Dose / Frequency    Amount 

Medication    Dose / Frequency    Amount 

Medication    Dose / Frequency    Amount 

Medication    Dose / Frequency    Amount 

Medication    Dose / Frequency    Amount 

Medication    Dose / Frequency    Amount 

Any Further requests or requirements:

                        Charges:   Faxed $15          Pickup   $12