In-house X-Ray Services
Our mission is to provide affordable best in class health care:
  - Affordable/Convenient - Same day/Weekday/weekend appointments
   - Most services available in premise (Lab/X-Ray/Pharmacy etc)
   - Contact us at your convenience via internet/phone/email
Bala Family Practice: Prescription Refill

Patient Name *
Enter your Full Name
Email Address *
Confirm Email Address *
Daytime Phone *
Evening Phone *
Date of Birth *

Enter Date of Birth
I would like to be contacted by Email or Phone: *
Email  Email 

Insurance Provider Information

Select Your Insurance Provider:
Name of Medication 1: *
Name of Medication 2:
Name of Medication 3:

Pharmacy Pickup Information

Call in my prescription.
I'll pick my prescription... (select one)
 At the Bala Family Practice Pharmacy 
 Call in to an external Pharmacy 

If you want us to call your prescription into your pharmacy, please select your pharmacy from the list below. Please be precise, there are hundreds of pharmacy locations in Bel Air.

Name of Pharmacy (obtain from label on current prescription):
Pharmacy Store Number
If your label has one, we need it:
Pharmacy Phone: *
Comments (optional):
Image Verification
Please enter the text from the image:
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