Medication Refill Requests

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One refill request must be completed for each patient.

Patient First Name *

Patient Last Name *

Patient Date of Birth *

YYYY

Patient Acknowledgement *

I acknowledge that I am the patient named on this form.

I acknowledge that I am the parent/legal guardian of the patient named on this form.

If Applicable: Name of parent/legal guardian filling out this form on behalf of a minor child.

Provider Name *

Michael Hickman

Shyler Bischof

Medication #1 Name *

Medication #1 Dosage *

Medication #2 Name

If applicable

Medication #2 Dosage

If applicable

Pharmacy Name and Location *

If your pharmacy is not included, please list pharmacy name and location in the following question.

If your pharmacy is not included in the dropdown list, please list pharmacy name and location here:

Controlled Substances Acknowledgement #1 *

A patient who is actively taking a controlled medication is required by law to meet with their Provider at least once every 3 months, and the appointment must be face-to-face.

Please note if you have not been seen in at least 3 months, your Provider will NOT refill your prescription until you are seen.

I acknowledge that to be eligible for this medication refill, I must have had a face-to-face appointment with my provider in the three months prior to my refill request.

Required

Controlled Substance Acknowledgement #2 *

I acknowledge that notwithstanding the date I submit this form, a controlled substance will be filled only within 30 days of issuance (or date the prescription is written).

Required

Is there anything else we should know?

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