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UHS Pharmacy Online Prescription Refills 1552 University Avenue Information on this form is kept confidential by the pharmacy staff. However, it is sent via email, and there are limits to the absolute security of email. If you prefer, you may order prescription refills by phone: 608-263-4990. Need to transfer a prescription to UHS? Download this form and fill in the information about your prescriptions. Send it to the pharmacy via fax (608-265-8714) or email to rxrefills@hosp.wisc.edu (send the form as an attachment, and put “University Health Services” in the subject line). Allow one business day before picking up your prescription. *[required fields are marked with ]**
Name	*
UW Student ID number	*
Telephone #1 (in case we have questions about your refill)	*
Telephone #2
Email
Prescription number [highlighted in yellow on your prescription label, and starts with “03”] example: 03-9876543	*
additional prescriptions:



Bill your insurance plan? [if we have an insurance plan on file for you, we can automatically direct the claim to them]		yes no
When would you like to pick up your prescription? Please give us one business day in advance. Today is Monday, May 12. Pharmacy hours: Mon \| Tue \| Thu \| Fri » 8:30 am to 5 pm Wed » 9 am to 5 pm		date time
Message: What quantity refill would you like? example: if you are ordering birth control, how many months do you want? Any other comments?

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