Prescription Refill Request Form
Francisca Okwukogu, 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 $30 fee applied to your account at the discretion of your provider. 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.
This form is not to be used for scheduling. Please call (703) 935-0058, dial 2, or email medmgmt@drgoldberg.org to get scheduled for an appointment.
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date of Birth
Email
*
example@example.com
Best Contact Phone Number
*
We will use this number to contact you if we have any questions about your request.
Can we leave a message on this number?
*
Yes
No
Do you have a scheduled appointment?
*
Yes
No
When is your next appointment scheduled?
*
-
Month
-
Day
Year
Date
Is this the same pharmacy your last prescription was sent to?
*
Yes
I want to use a different pharmacy
Pharmacy Name
*
Prescription Refill #1
Exact Prescription Name
*
Dosage (mg/unit)
*
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)
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)
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.
Urgent and emergent messages are not to be left via this method of communication. This inbox is not constantly monitored. If you are experiencing an emergency, proceed to your nearest emergency room or dial 911. You can reach the Suicide & Crisis Lifeline by dialing 988. Other resources include local Community Service Boards.
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