Medication Refill Request Form

Medication Refill Request Form

You must have a follow-up appointment scheduled in order to receive a full month supply of medication.
Patient Name:*

First NameLast Name
Patient Date Of Birth: *

MonthDayYear
Date
Phone Number: *
Please enter a valid phone number.
Do you have a follow-up scheduled?*

YesNo
If you don't have one scheduled, please pick your desired date for your next appointment:
What medication do you need refilled?*
What pharmacy do you want it sent to? *
Please make sure to input name of pharmacy, address and zip code
Please explain briefly, why you need a refill of your medication. (I.e., you missed your last appointment and ran out of medications, you have not had a follow-up in a while, etc.). *
As according to New York State Law, you cannot get more than 30 days supply of a controlled substance. If you have not had a follow-up scheduled in the past 30 days, and are requesting a refill of medication, especially if it is a controlled substance, you can only get a maximum of a 10 day supply.
Should be Empty: