Medication Refill Request

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Please contact your pharmacy first before submitting a refill request.

Please answer the following questions as accurately as possible. Please allow 48 hours to be notified of the status of your request.

We will not process any ADHD/ADD schedule 2 controlled substance refill requests through this form, requests will be rejected. You must have an appointment scheduled to discuss a refill request at with your provider.

Have you contacted your pharmacy first to request a refill? *

Yes

Patient's first name *

Patient's last name *

Date of birth *

YYYY

Phone number *

Email address *

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