Prescription Refill Form

Prescription Refill Request Form
Are you requesting this prescription for yourself or for your child?*

MyselfMy child
Patient Information:
Parent/Guardian's Full Name:
Patient's Full Name:*
Prescription Information:
Who is your prescriber?*

Laura Carlson, M.D.Rebecca Cho, M.D.Brandon Gimbel, M.D.Marisa Perez-Reisler, M.D.Chadwick Yip, M.D.I’m not sure / General office
Is this a new prescription request or a follow-up due to pharmacy shortage or other issue?*

NewFollow-up
Please describe the issue with your previous prescription:
How many medications are you requesting?*
Medication 1 Name:
Medication 1 Dose & Frequency:
(e.g., 20mg, twice daily)
Is this a stimulant medication?

YesNo
Please note that stimulant prescriptions require additional review and may take extra time to process.

Additionally, stimulant prescriptions will only be sent once 30 days have passed since your most recent fill date. Requests submitted before this timeframe cannot be processed early.
Medication 2 Name:
Medication 2 Dose & Frequency:
(e.g., 20mg, twice daily)
Is this a stimulant medication?

YesNo
Please note that stimulant prescriptions require additional review and may take extra time to process.

Additionally, stimulant prescriptions will only be sent once 30 days have passed since your most recent fill date. Requests submitted before this timeframe cannot be processed early.
Medication 3 Name:
Medication 3 Dose & Frequency:
(e.g., 20mg, twice daily)
Is this a stimulant medication?

YesNo
Please note that stimulant prescriptions require additional review and may take extra time to process.

Additionally, stimulant prescriptions will only be sent once 30 days have passed since your most recent fill date. Requests submitted before this timeframe cannot be processed early.
Medication 4 Name:
Medication 4 Dose & Frequency:
(e.g., 20mg, twice daily)
Is this a stimulant medication?

YesNo
Please note that stimulant prescriptions require additional review and may take extra time to process.

Additionally, stimulant prescriptions will only be sent once 30 days have passed since your most recent fill date. Requests submitted before this timeframe cannot be processed early.
Medication 5 Name:
Medication 5 Dose & Frequency:
(e.g., 20mg, twice daily)
Is this a stimulant medication?

YesNo
Please note that stimulant prescriptions require additional review and may take extra time to process.

Additionally, stimulant prescriptions will only be sent once 30 days have passed since your most recent fill date. Requests submitted before this timeframe cannot be processed early.
Pharmacy Information:
Do you wish us to use the same pharmacy as your last fill?*

YesNo
Pharmacy Name:
Pharmacy Phone Number:
Pharmacy Street Address and Zip Code:
Final Steps
Best Contact Method for Follow-up (Dropdown: Phone, Email, Text):*
Phone Number for Follow-up:
Please enter a valid phone number.
Email for Follow-up:
example@example.com
I understand that refill requests may take 1-2 business days and may require an appointment if additional evaluation is needed.*

I agree.
Should be Empty:

Prescription Refill Request Form

Patient Information:

Prescription Information:

Pharmacy Information:

Final Steps