Prescription Refill Request Patient Name Phone Number Name of Prescription Drug Or Type of Contact Lens Preferred Pharmacy Preferred PharmacyAlbertson'sToddysWal-MartK Mart SupercenterKing Soopers 11th AveKing Soopers 35th AveLongs DrugRite Aid PharmacySafeway 10th AveSafeway 11th Ave Other Pharmacy Choose The Doctor You Normally Visit Choose The Doctor You Normally VisitDr. John WelchDr. Matt UyemuraDr. Rochelle BrotskyDr. Samuel Jeng How Would You Like To Be Contacted? How Would You Like To Be Contacted? By Phone By Email Email 9 + 6 = Submit Request An AppointmentFor routine appointments only. Please call us at 970-352-6688 if it is an emergency. *Patient Name *Phone *Date of Birth *What is Your Primary Language? *What is Your Primary Language? English Spanish *Tell Us About the Service You Need Provided Submit Welch Eye Center1616 15th St. Greeley, CO 80631 970-352-66881616 15th St.Greeley, CO 80631
