Pharmacy

Refill Request

Seattle Children's Hospital Pharmacy Refill Request

We only fill prescriptions for medicines prescribed by a Seattle Children’s provider.
Use this form to pick up refills from Seattle Children’s Bellevue or Seattle Children’s main campus (in Seattle).
Do not use this form if you want to pick up a refill at another pharmacy. You’ll need to contact them directly.
Which Seattle Children's Pharmacy location will you be picking up the medication from?*:

Patient Information
First Name*: Last Name*:
Birth Date (mm/dd/yyyy)*:
Medical Record Number:
Your Information
Your Name*:
Email Address:
Phone Number*:
This is the number we will call if there will be a delay in filling the prescriptions or if we have any questions.
Click here if you would like us to call this number when the medication is ready for pick up.
Prescription Information
Prescription Numbers or Medication Names*:
+ Add another prescription
When are you planning on picking up the medication?
Please allow at least 24 hours.
If the prescription is out of refills please allow at least 72 hours.
Date*: Time:
Additional Information: (100 characters left)
Please retype the characters from the picture:
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