ASTRA BH MEDICATION REFILL REQUEST

Are you requesting a refill for Suboxone, Subutex, Sublocade, Naltrexone, Vivitrol, or Depade?*

YESNO

Please contact the ASTRA office where you see your provider for these medications to schedule a follow-up appointment as soon as possible. We are unable to process refill request orders for MAT (Medication Assisted Treatment) medications.

Patient's First and Last Name*

First and Last Name

Date of Birth*

ASTRA BH provider you see for medications

ASTRA BH Provider's Office Location*

When is your prescription refill(s) due?

Date

How many medications are due for a refill?

MEDICATION REFILL REQUEST #1
Please enter the name of the medication here: Medication Name
What is the milligram (mg) dose: Medication Milligram
Date of last refill: Date of last prescription

MEDICATION REFILL REQUEST #2
Please enter the name of the medication here: Medication Name
What is the milligram (mg) dose: Medication Milligram
Date of last refill: Date of last prescription

MEDICATION REFILL REQUEST #3
Please enter the name of the medication here: Medication Name
What is the milligram (mg) dose: Medication Milligram
Date of last refill: Date of last prescription

MEDICATION REFILL REQUEST #4
Please enter the name of the medication here: Medication Name
What is the milligram (mg) dose: Medication Milligram
Date of last refill: Date of last prescription

MEDICATION REFILL REQUEST #5
Please enter the name of the medication here: Medication Name
What is the milligram (mg) dose: Medication Milligram
Date of last refill: Date of last prescription

Preferred Pharmacy

NAME OF PHARMACY

Pharmacy Address

ENTER FULL ADDRESS

Do you have a scheduled follow-up appointment with your provider?*

YESNO

Please contact (270) 506-2730 as soon as possible to schedule a follow-up appointment.

Please contact (270) 321-4480 as soon as possible to schedule a follow-up appointment.

Please contact (502) 349-3100 as soon as possible to schedule a follow-up appointment.

Please contact (502) 694-4820 as soon as possible to schedule a follow-up appointment.

If your medication requires a drug screen, have you completed a drug screen prior to this request?*

YESNOMy prescription does not require a drug screen

Please visit the ASTRA office location where you receive services to complete your drug screen. PLEASE NOTE: Before we are legally able to refill specific medications, your urine drug screen must be completed within our office.

Additional information (adverse side effects from the medication(s), new prescriptions or over the counter meds, changes in your medical/psychiatric history, etc.):

Are you under the care of a parent or legal guardian?*

YESNO

Name of parent/legal guardian submitting this request*

First and Last Name

By signing, you acknowledge that you have authorized access to the patient's protected health information, and is under your care.*