Medication Refill Request JWC

Medication Refill & Inquiry Request

Please submit the request or question below and allow for 3 business days for a staff member to respond. *Please note any controlled medication will not be eligible for a refill without an appointment with one of our prescribers. Please call the office to schedule with your provider if you are out of any controlled medications.
Medication Refill Request & medical inquiries are for the convenience of our current patients. This helps minimize phone calls and allows our office staff to attend to your needs quickly and efficiently.

Please note, if you do not wish to submit protected health infromation you should call the office and address your request with a staff member. This form is intended to address your refill request quickly and calling into the office can increase turn around time to address.

Repeated medication refill requests will not be authorized. Additionally, patients who have not been seen in the office for a long time or who frequently miss their appointments may not be provided with refills. All patients who are authorized refills must have an upcoming appointment with their provider scheudled. Please call to schedule an appointment if you do not already have one.

Fill in the form completely including the accurate pharmacy infromation. It may take up to 3 business days to complete a refill request or longer if during weekends and holidays. Please do not call the office to check on the status of your request.

Please call your pharmacy to see if they've received your presrciption or have a refill on file for you before submitting this request.
Please Read the Following

Check with your pharmacy if you have any refills left on your last prescription or if their are any new prescriptions under your name before sending in this request. If there is refills or new prescriptions at the pharamacy we will not address this refill request.
Patient Information
Patient Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date of birth
Patient Email
example@example.com
Patient Phone Number*
I agree to allow JADE Wellness Center to contact me?

YesNo
By submitting this form via this web portal, you acknowledge and accept that risks of communicating your health information via this unencrypted email and electronic messaging and wish to continue despite those risks. By clicking "Yes, I want to submit this form" you agree to hold JADE Wellness Center harmless for unauthorized use, disclosure, or access of your protected health information sent via this electronic means.*

Yes
JADE Wellness Center Location
Date of Next Appointment*

MonthDayYear
Date
Is this a medication refill request?*

YesNo
Pharmacy Information
Pharmacy Name:*
Pharmacy Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Pharmacy Phone Number*
Please enter a valid phone number.
Pharmacy Fax Numer
Please enter a valid phone number.
Medications Needed
Prescription written by:*
Medication Name*
Dosage taken per day*
Medication Name
Dosage taken per day
Medication Name
Dosage taken per day
Please provide context as to why you are requesting this medication refill:*
Please provide details regarding your inquiry below.
Should be Empty:

Medication Refill & Inquiry Request

Please Read the Following

Patient Information

Pharmacy Information

Medications Needed