Prescription Refill Request

Please enter the information in the form below to request a prescription refill.  Press the "Send Prescription Request" button to send your request.  You will receive an acknowledgement E-mail when a representative of the clinic has received your request.  Only use the prescription request form below for non-urgent requests.  Note:  If you have not received an acknowledgement E-mail that your request was received within 24 hours on normal business hours, please call 920-996-1065

E-Mail requests will be processed Monday through Friday from 8AM - 4:30PM.  

Your prescription will be available at the pharmacy by the end of the next business day.  Some exceptions may apply.  Requests sent after normal business hours will not be read until the next business day.  

This E-mail communication is for the purpose of prescription refills only.  If this is an emergency, call 911. 

If you prefer to make a Prescription Refill Request by phone, please call Primary Care Associates' Prescription Line at 920-996-1065.

You must be an adult (18 years old or older) to request a prescription refill by E-mail through the internet. If you are a minor (17 years old or younger), please call Primary Care Associates at 920-996-1000 and speak directly with your Physician's Nurse. 

When you press the "Send Prescription Request" button, you consent to correspond with Primary Care Associates staff by E-mail through the Internet.  

Primary Care Associates CANNOT GUARANTEE THAT THE INFORMATION YOU PROVIDE IN YOUR PRESCRIPTION REFILL REQUEST WILL REMAIN CONFIDENTIAL WHEN SUBMITTED BY E-MAIL THROUGH THE INTERNET. When you press the "Send Prescription Request" button, you aGREE TO RELEASE Primary Care Associates of ANY AND ALL LIABILITY THAT MAY ARISE OR IS RELATED TO DISCLOSURES OF INFORMATION that YOU PROVIDE IN YOUR PRESCRIPTION REFill REQUEST.  

* Indicates Required Field