Prescription Refill Form

 

Refill requests are processed at 10:00 am and 3:00 pm, Monday through Friday.

Requests may take 1-2 days to be processed.

1. In order for a refill request to be processed, you must have an appointment scheduled with the prescribing physician or nurse practitioner.

2. If you do not have an appointment scheduled, please contact the scheduling secretary to set one up before completing this request.

3. To have a prescription refilled, we will need all of the information completed below.

4. Once you have filed your request, if we require additional information, we will contact you. Otherwise, please check with your pharmacy for the status of your refill.

Doctor or Nurse Practitioner’s Name (required):

My or my child’s next scheduled appointment is (required):

(If you do not have a next appointment scheduled, call the scheduling secretary to do so before completing this form. Refill requests will not be acted upon unless you have a future appointment.)

Patient First Name (required):

Patient Last Name (required):

Patient Date of birth (required):

Telephone number (required):

Pharmacy Name (required):

Pharmacy Address (required):

Pharmacy City/Town (required):

Pharmacy State (required):

Please copy the following from the medication bottle:

Medication you would like refilled (required):

Dosage (required):

Frequency (required):

If a paper prescription is required, please indicate your preference

 Mail it to me I will pick it up

Any other information you may want to add:

Name of person completing this form, if other than patient (required):