Refill Request

For prescription refills, please call your pharmacy and have them send a refill request. If you are having difficulty getting a hold of your pharmacy for a refill request after 2 business days, please fill out the following form, which will be sent to your provider.
Controlled medications (i.e. Adderal, Xanax) prescribed outside of scheduled appointments will be charged a $20 prescription refill fee.
Please fill out ALL SECTIONS and then hit “Submit Refill Request” button.
Refills will be automatically denied if a section is missing. Thank you!

Name of Provider

Your Name

Date of Birth

YYYY

Best Phone Number to Reach You

(###)

###

####

Email address

Preferred Pharmacy (Please include address and phone number)

Medication being requested (e.g. Advil). Please include dose (e.g. 200 mg) and how you are taking the medication (e.g. twice a day)

Further comment/instructions (optional)

Please check the following box

I understand that this is a refill request. IT DOES NOT MEAN THAT I WILL RECEIVE THE MEDICATION. My provider will carefully review the request and determine whether to approve it, deny it, or request a follow-up appointment.