Home About Medical Staff Services For Patients For Physicians Learning Center News Contact For Patients Prescription Request To request a Prescription refill please fill in the form below and click the Request Prescription button when finished. Fields marked with a * are required fields. If your medication need is urgent or you prefer to make your request over the phone, call us at (920) 882-8200 or toll-free at (888) 231-5236. Patient Name*:   Sex Male Female Birthdate*:   Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 28 29 30 31 Year 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 1900 E-mail*:   Phone*:   Choose Type Home Phone Work Phone Cell Phone Other Name of Doctor*:   Choose a Doctor Thomas M. Wascher, M.D., FACS Karl A. Greene, M.D., PhD., FACS Peter F. Ullrich, Jr., M.D. Richard A. Staehler, M.D. John P. Revord, M.D. J. Talbot Sellers, DO Randall J. Schultz, M.D. Douglas J. Hendricks, M.D. David D. DeWitt, M.D. None Assigned Name of Medication*:   Milligrams (mg)*:   Times Taken Per Day*:   Choose... 1 2 3 4 5 6 7 8 Amount Taken Per Dose*:   Choose... 1 2 3 4 5 6 7 8 Pharmacy Name*:   Pharmacy Phone*:   Street Pharmacy Is On*:   Pharmacy City/State*:   Comments (e.g. allergies to medications, other medications currently taking, etc.):         5320 West Michaels Drive   |   Appleton, WI 54913-8400   |   Phone: (920) 882-8200 or (888) 231-5236   |   Fax: (920) 882-8210