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.

Please Read The Following

Check with your pharmacy if you have any refills left on your last prescription before sending in this request. Use for medications refill request only. Do not use this for any other purposes.

It can take 1 -3 days to respond to your request, longer if requested on Fridays or during holidays. Check with your pharmacy about the status of your prescription in 24 – 72 hours. You do not need to call the office. We will let you know if medications will not be called in for any reason/s.

*Controlled medications cannot be faxed or called in to a pharmacy (i.e, Ritalin, Adderall, Concerta). These prescriptions must be picked up at our office.
Patient Information
Patient Name*
First Last
Date of Birth*
Date Format: MM slash DD slash YYYY
Patient Email*
Patient Home/Main Phone Number*
Patient Cell Phone Number
Date of Next Appointment*
Date Format: MM slash DD slash YYYY
Pharmacy Information
Pharmacy Name*
Pharmacy Address*
Street Address Address Line 2 City State ZIP Code
Pharmacy Phone Number*
Pharmacy Fax Number
Medications Needed
Prescription written by:*
Medication Name*
Dosage taken per day*
Medication Name
Dosage taken per day
Medication Name
Dosage taken per day
Additional Comments
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Medications / Refill Request Form

Please Read The Following

Patient Information

Pharmacy Information

Medications Needed

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