Refill Request Form

**Please allow 48hrs to fill. If you are picking up at our office during business hours, then we will text you when it is ready for pick up**

* Indicates required field

Name *

First

Last

Email *

Please complete the address section ONLY if you are requesting us to ship your medications. Shipping charges will apply.

Address *

City *

State *

Medication #1 *

Dose *

How often do you take it? *

Pick up options *

Medication #2 *

Dose *

How often do you take it? *

Pick up options *

Medication #3 *

Dose *

How often do you take it? *

Pick up options *

Please list other medications here (Please include name, dose, frequency) *

Submit

We are passionate about practicing medicine the way it should be.

HOURS OF OPERATION
MON-THR 9a - 5p
FRI 9a - 12p
SAT/SUN CLOSED

OUR OFFICE IS CLOSED:
Labor Day (Sept 7th)
Thanksgiving (Nov 25-27th)
Christmas (Dec 24, 25)
New Year (Dec 31st-Jan 1)

6650 West 110th Street
Suite 220
Overland Park, KS 66211

T: (913) 549-3884
E: Info@Liveactivepc.com