Prescription Refill Request Form
Michelle Holder, PMHNP
Refills are typically completed within 3-5 business days unless any clarification or further information is needed. If you have not been seen within 3 months, an appointment is required. Controlled substances, such as stimulants, can not be prescribed outside of the providers licensed jurisdiction. If you are completely out of your medication and are in need of immediate care, please go to your nearest emergency room.
If you are requesting a medication refill but missed your last appointment, please be aware that the refill will be sent with a $25 fee applied to your account. An appointment will also need to be scheduled - please call (703) 935-0058 and press 1 to schedule a follow-up appointment with your provider.
Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
Date
Can we leave a message on this number?
*
Yes
No
Best Contact Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Pharmacy Name
*
Is this the same pharmacy your last prescription was sent to?
Yes
I would like to use a different pharmacy
Pharmacy Address (Please enter if you are using a different pharmacy than your previous prescription was sent to.)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Pharmacy Phone Number
Please enter if a new pharmacy is being used.
Pharmacy Fax Number (if known)
Please enter a valid phone number.
Prescription Refill #1
Exact Prescription Name
*
Dosage (mg/unit)
*
How frequently do you take this medication?
*
i.e. Once a day, twice a day, etc.
When will you run out of this medication?
*
Prescription Refill #2
Only need to complete if you have multiple medications that need to be refilled.
Exact Prescription Name
Dosage (mg/unit)
How frequently do you take this medication?
i.e. Once a day, twice a day, etc.
When will you run out of this medication?
Prescription Refill #3
Only need to complete if you have multiple medications that need to be refilled.
Exact Prescription Name
Dosage (mg/unit)
How frequently do you take this medication?
i.e. Once a day, twice a day, etc.
When will you run out of this medication?
Please include any other additional information you feel is needed for your provider to complete your request.
Please do not leave any emergent messages on this form.
Submit
Should be Empty: