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Online Prescription Refill Request

Please provide the following contact information:

Full Name:
Student ID#:
Phone#:
E-Mail:
Please provide the following prescription information:
1)	Name and Strength of Medication:	Please enter name and strength of medication
	Rx# (upper left corner of label)
	Quantity of medication:
Additional Prescriptions:
2)	Name and Strength of Medication:
	Rx# (upper left corner of label)
	Quantity of medication:

3)	Name and Strength of Medication:
	Rx# (upper left corner of label)
	Quantity of medication:

4)	Name and Strength of Medication:
	Rx# (upper left corner of label)
	Quantity of medication:

5)	Name and Strength of Medication:
	Rx# (upper left corner of label)
	Quantity of medication:
I understand that every effort has been made to ensure my privacy, but full confidentiality cannot yet be guaranteed in an electronic medium. Indicate understanding/acceptance.

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Student Health Services Contact Page

University of North Dakota • Grand Forks, ND 58202 • Toll Free: 1-800-CALL-UND • Tel: 701-777-2011
©2004 University of North Dakota. Send questions/comments about this web site to the SOS Division Webmaster.

UND Student Health Services
McCannel Hall, Room 100
Box 9038
Grand Forks, ND 58202
Tel: 701.777.4500
Email: student_health@und.nodak.edu