Medication and Prescription Refills
Your name:
Date of Birth:
Email address:
Phone number:
Pharmacy Name
Pharmacy
Phone Number:
Office location of
your last exam:
Name of Doctor:
Comments:
Tired of losing the little slips of paper you get at the doctors office?  
Why not get your prescriptions filled electronically?  
Getting your prescriptions to your neighborhood pharmacy is as easy as 1-2-3!
We can send your prescriptions to your local neighborhood CVS, Walgreens,
Walmart, or other pharmacy.
Simply fill out the form below making sure to include your pharmacy address
and telephone number.  
You will be contacted to confirm the medications and pharmacy information you
would like entered into the system.
Downtown  (713) 659-3937
East Houston Eye Center  (713) 453-3521
Webster/Clear Lake  (281) 332-1559
Charles A. Garcia, M.D., P.A.
Exceptional Eye Care in Houston