Welcome to Henderson & Walton Women's Center Online!

Prior Authorization Forms

Pregnancy
Guide

Using medications during pregnancy

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The prescription requests are only for REFILLS without any changes from a prior prescription. No new prescriptions will be handled online. If you need a new prescription or a change in the prescription, please contact our office at (205) 930-1800 or 1-800-264-1075. This website may be used for refill of routine maintenance medications, (blood pressure, birth control, hormones, etc.). We will be happy to refill these prescriptions only if you are up to date on your yearly exam. Allow approximately 3 business days after sending us the request and the pharmacy to process the request. Requests done over the weekend will be handled on Monday morning. Please call your pharmacy before picking up your prescription to ensure that the request has been filled. If your pharmacy has not received the prescription, please call us to check on the status of the refill request. If you need pain medication or any controlled substance you will need to call our office. These requests will not be handled online. Disclaimer: This Rx Refill Form is to be used for your convenience for HWWC informational purposes. By submitting this information, you are agreeing to send your information electronically. If you have a medical Emergency, please seek attention from your primary caregiver or dial 911.
* Indicates required information
Patient Name: *
Date of Birth: *	(mm/dd/yyyy)
Contact Phone Number: *
Alternate Contact Number
Doctor: *
Drug Requested: *
Drug Dose: *
How often do you take this medication?: *
Please list any Allergies: *
Pharmacy Name: *
Pharmacy Phone Number: *
Any Other Information:
Email Address ( Your information will not be shared ):

Disclaimer: This Rx Refill Form is to be used for your convenience for HWWC informational purposes only. If you have a medical Emergency, please seek attention from your primary caregiver or dial 911.