Prescription Refill Request
​This prescription refill request form is for the convenience of our current patients. We require most patients to be seen every 3 months to ensure medication efficacy and tolerability prior to authorizing medication refills. Patients who have not been seen in the office in the past 3 months or who frequently miss their appointments may not be provided with refills.

Before completing this form, please check with your pharmacy to be sure that you do not have refills on file. Often, when we send in refills, the pharmacy stores them as new prescriptions rather than refills. So, although your medication bottle may say you have no refills, you may actually have a new prescription on file.

Please note, we typically require 48 hours to process refill requests. If you require your refill sooner than that, please be sure to mark this request as urgent. On Fridays, our medical staff checks refill requests at 4PM. On weekends and holidays, our medical staff checks refill requests at 9AM and 4PM. urgent requests will be handled at those times. Once you are alerted that your refill has been sent, it is your responsibility to follow-up with the pharmacy to ensure timely filling as weekend and holiday pharmacy hours vary.
Sign in to Google to save your progress. Learn more
Is this request urgent? *
Refill requests are typically addressed within 48 hours. Should you require an immediate refill, please be sure to mark this request as urgent.
Patient's first and last name: *
Patient's date of birth: *
MM
/
DD
/
YYYY
Date of next scheduled medication management appointment: *
Please note, controlled substances will not be refilled if you broke (late cancel or no show) your last appointment. Additionally, most patients must be seen once every 3 months in order to receive refills.
MM
/
DD
/
YYYY
Who prescribes the medication needing refilled? *
Pharmacy name: *
Pharmacy address (street, city, zip code): *
Is this a different pharmacy than we currently have on file for you? *
Medication to be refilled (please include dosage and instructions): *
Medication to be refilled (please include dosage and instructions):
Medication to be refilled (please include dosage and instructions):
Medication to be refilled (please include dosage and instructions):
Notes to medical staff (ie - reason for early refill request, need to change pharmacy, etc):
Preferred method of contact to alert that refill has been sent to the pharmacy: *
Email address or phone number to alert that refill has been sent to pharmacy: *
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of discovertranquility.com. Report Abuse
Google Forms