Medications / Refill Request Form
The MEDICATION REFILLS REQUEST form is for the convenience of our current patients. This helps minimize phone calls and allows our office staff to attend to your needs while you are in the office.
Repeated medication refill requests will not be authorized. Additionally, patients who have not been seen in the office for a long time or who frequently miss their appointments may not be provided with refills. We do not fax prescriptions to mail order pharmacies nor do we fax or call in prescriptions to some local pharmacies that frequently have busy phone/fax lines.
Fill in the form clearly with the exact name of the medication, dose, and directions in addition to your pharmacy information. Do not call the office to check the status of your request. It may take up to 72 hours or longer during holidays or weekends to send in your script. Call your pharmacy to check if they have received the script. You should have more than 3 days of medications left at home when you request a refill. We expect our patients to be responsible for their medications and be an active participant in their treatment.
*There will be a $20 charge for replacement of lost scripts.