Refill Requests During COVID-19 Pandemic

If you are a current patient (active within the last 12 months) at the Ithaca Free Clinic, we will be honoring refills during this difficult time.

Please fill out the form below and wait to be contacted. If there are questions we will email you, and once submitted for refill, we will notify you of completion. Thank you.

Prescription Refill

First Name:

Last Name:

Date of Birth:

Phone: #


Name of Prescription Medication:

Additional Info:

Herbal Refill

First Name

Last Name

Date of Birth

Phone #


Name of Herbal Medication

Additional Info: