www.eyeconsultants.net - MED REFILL REQUEST FORM

Our staff will give your request and medical chart to your physician for review. We will contact you when the prescription has been called in to your pharmacy. We process Med Refill forms from 8:00 AM to 4:00 PM Monday through Friday.

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Medication Name #1:	Glaucoma Medications Alphagan P .1% Alphagan P .15% Azopt Acetazolamide 500mg Betagan .25% Betagan .5% Betimol .5% Betoptic S Brimonidine 0.15% Carteolol Combigan Cosopt Diamox 250mg Diamox 500mg Dorzolamide Dorzolamide/Timolol Iopidine Isopto Carbachol Istalol Latanoprost Levobunolol Lumigan .01% Lumigan .03% Methazolamide 50mg Metipranolol Optipranolol Phospholine Iodide 0.125% Pilocarpine 1% Pilocarpine 2% Pilocarpine 3% Pilocarpine 4% Timolol 0.25% Timolol 0.5% Timoptic 0.25% Timoptic 0.5% Timoptic XE 0.25% Timoptic XE 0.5% Travatan Z Trusopt Xalatan Antibiotics Azasite Bacitracin Bepreve Besivance Ciloxan drops Ciloxan ointment Doxycycline 100mg Doxycycline 50mg Erythromycin oint Gentamicin drops Gentamicin oint Iquix Keflex 500mg Neomycin oint Neosporin oint Ocuflox drops Polysporin oint Tobrex drops Tobrex oint Quixin Vigamox Zymar Zymaxid Steroids Alrex Dexamethasone/tobramycin (generic for Tobradex) FML Forte Lotemax 0.5% Maxitrol drops Maxitrol oint Poly-pred Pred Forte 1% Pred Mild Tobradex drops Tobradex oint Vexol Zylet Anti-Fungal Acyclovir Natacyn Valacyclovir Valtrex Viroptic drops Zirgan Zovirax Anti-Inflammatory (non-steroid) Acular .5% Acular LS .4% Acuvail Bromday Ketoralac Ocufen Voltaren drops Xibrom Allergy Alamast Alocril 2% Alomide .1% Crolom 4% Optivar .5% Pataday Patanol Zaditor Other Restasis Latisse Cyclogyl 1% Cyclopentolate 1% Atropine 1%
Directions #1:
Medication Name #2:	Glaucoma Medications Alphagan P .1% Alphagan P .15% Azopt Acetazolamide 500mg Betagan .25% Betagan .5% Betimol .5% Betoptic S Brimonidine 0.15% Carteolol Combigan Cosopt Diamox 250mg Diamox 500mg Dorzolamide Dorzolamide/Timolol Iopidine Isopto Carbachol Istalol Latanoprost Levobunolol Lumigan .01% Lumigan .03% Methazolamide 50mg Metipranolol Optipranolol Phospholine Iodide 0.125% Pilocarpine 1% Pilocarpine 2% Pilocarpine 3% Pilocarpine 4% Timolol 0.25% Timolol 0.5% Timoptic 0.25% Timoptic 0.5% Timoptic XE 0.25% Timoptic XE 0.5% Travatan Z Trusopt Xalatan Antibiotics Azasite Bacitracin Bepreve Besivance Ciloxan drops Ciloxan ointment Doxycycline 100mg Doxycycline 50mg Erythromycin oint Gentamicin drops Gentamicin oint Iquix Keflex 500mg Neomycin oint Neosporin oint Ocuflox drops Polysporin oint Tobrex drops Tobrex oint Quixin Vigamox Zymar Zymaxid Steroids Alrex Dexamethasone/tobramycin (generic for Tobradex) FML Forte Lotemax 0.5% Maxitrol drops Maxitrol oint Poly-pred Pred Forte 1% Pred Mild Tobradex drops Tobradex oint Vexol Zylet Anti-Fungal Acyclovir Natacyn Valacyclovir Valtrex Viroptic drops Zirgan Zovirax Anti-Inflammatory (non-steroid) Acular .5% Acular LS .4% Acuvail Bromday Ketoralac Ocufen Voltaren drops Xibrom Allergy Alamast Alocril 2% Alomide .1% Crolom 4% Optivar .5% Pataday Patanol Zaditor Other Restasis Latisse Cyclogyl 1% Cyclopentolate 1% Atropine 1%
Directions #2:
Medication Name #3:	Glaucoma Medications Alphagan P .1% Alphagan P .15% Azopt Acetazolamide 500mg Betagan .25% Betagan .5% Betimol .5% Betoptic S Brimonidine 0.15% Carteolol Combigan Cosopt Diamox 250mg Diamox 500mg Dorzolamide Dorzolamide/Timolol Iopidine Isopto Carbachol Istalol Latanoprost Levobunolol Lumigan .01% Lumigan .03% Methazolamide 50mg Metipranolol Optipranolol Phospholine Iodide 0.125% Pilocarpine 1% Pilocarpine 2% Pilocarpine 3% Pilocarpine 4% Timolol 0.25% Timolol 0.5% Timoptic 0.25% Timoptic 0.5% Timoptic XE 0.25% Timoptic XE 0.5% Travatan Z Trusopt Xalatan Antibiotics Azasite Bacitracin Bepreve Besivance Ciloxan drops Ciloxan ointment Doxycycline 100mg Doxycycline 50mg Erythromycin oint Gentamicin drops Gentamicin oint Iquix Keflex 500mg Neomycin oint Neosporin oint Ocuflox drops Polysporin oint Tobrex drops Tobrex oint Quixin Vigamox Zymar Zymaxid Steroids Alrex Dexamethasone/tobramycin (generic for Tobradex) FML Forte Lotemax 0.5% Maxitrol drops Maxitrol oint Poly-pred Pred Forte 1% Pred Mild Tobradex drops Tobradex oint Vexol Zylet Anti-Fungal Acyclovir Natacyn Valacyclovir Valtrex Viroptic drops Zirgan Zovirax Anti-Inflammatory (non-steroid) Acular .5% Acular LS .4% Acuvail Bromday Ketoralac Ocufen Voltaren drops Xibrom Allergy Alamast Alocril 2% Alomide .1% Crolom 4% Optivar .5% Pataday Patanol Zaditor Other Restasis Latisse Cyclogyl 1% Cyclopentolate 1% Atropine 1%
Directions #3:
Medication Name #4:	Glaucoma Medications Alphagan P .1% Alphagan P .15% Azopt Acetazolamide 500mg Betagan .25% Betagan .5% Betimol .5% Betoptic S Brimonidine 0.15% Carteolol Combigan Cosopt Diamox 250mg Diamox 500mg Dorzolamide Dorzolamide/Timolol Iopidine Isopto Carbachol Istalol Latanoprost Levobunolol Lumigan .01% Lumigan .03% Methazolamide 50mg Metipranolol Optipranolol Phospholine Iodide 0.125% Pilocarpine 1% Pilocarpine 2% Pilocarpine 3% Pilocarpine 4% Timolol 0.25% Timolol 0.5% Timoptic 0.25% Timoptic 0.5% Timoptic XE 0.25% Timoptic XE 0.5% Travatan Z Trusopt Xalatan Antibiotics Azasite Bacitracin Bepreve Besivance Ciloxan drops Ciloxan ointment Doxycycline 100mg Doxycycline 50mg Erythromycin oint Gentamicin drops Gentamicin oint Iquix Keflex 500mg Neomycin oint Neosporin oint Ocuflox drops Polysporin oint Tobrex drops Tobrex oint Quixin Vigamox Zymar Zymaxid Steroids Alrex Dexamethasone/tobramycin (generic for Tobradex) FML Forte Lotemax 0.5% Maxitrol drops Maxitrol oint Poly-pred Pred Forte 1% Pred Mild Tobradex drops Tobradex oint Vexol Zylet Anti-Fungal Acyclovir Natacyn Valacyclovir Valtrex Viroptic drops Zirgan Zovirax Anti-Inflammatory (non-steroid) Acular .5% Acular LS .4% Acuvail Bromday Ketoralac Ocufen Voltaren drops Xibrom Allergy Alamast Alocril 2% Alomide .1% Crolom 4% Optivar .5% Pataday Patanol Zaditor Other Restasis Latisse Cyclogyl 1% Cyclopentolate 1% Atropine 1%
Directions #4:
Medication Name #5:	Glaucoma Medications Alphagan P .1% Alphagan P .15% Azopt Acetazolamide 500mg Betagan .25% Betagan .5% Betimol .5% Betoptic S Brimonidine 0.15% Carteolol Combigan Cosopt Diamox 250mg Diamox 500mg Dorzolamide Dorzolamide/Timolol Iopidine Isopto Carbachol Istalol Latanoprost Levobunolol Lumigan .01% Lumigan .03% Methazolamide 50mg Metipranolol Optipranolol Phospholine Iodide 0.125% Pilocarpine 1% Pilocarpine 2% Pilocarpine 3% Pilocarpine 4% Timolol 0.25% Timolol 0.5% Timoptic 0.25% Timoptic 0.5% Timoptic XE 0.25% Timoptic XE 0.5% Travatan Z Trusopt Xalatan Antibiotics Azasite Bacitracin Bepreve Besivance Ciloxan drops Ciloxan ointment Doxycycline 100mg Doxycycline 50mg Erythromycin oint Gentamicin drops Gentamicin oint Iquix Keflex 500mg Neomycin oint Neosporin oint Ocuflox drops Polysporin oint Tobrex drops Tobrex oint Quixin Vigamox Zymar Zymaxid Steroids Alrex Dexamethasone/tobramycin (generic for Tobradex) FML Forte Lotemax 0.5% Maxitrol drops Maxitrol oint Poly-pred Pred Forte 1% Pred Mild Tobradex drops Tobradex oint Vexol Zylet Anti-Fungal Acyclovir Natacyn Valacyclovir Valtrex Viroptic drops Zirgan Zovirax Anti-Inflammatory (non-steroid) Acular .5% Acular LS .4% Acuvail Bromday Ketoralac Ocufen Voltaren drops Xibrom Allergy Alamast Alocril 2% Alomide .1% Crolom 4% Optivar .5% Pataday Patanol Zaditor Other Restasis Latisse Cyclogyl 1% Cyclopentolate 1% Atropine 1%
Directions #5:
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