Med Refill Program

Starlight Medication Refill Form
Welcome to the Starlight Medication Refill Program!

Sometimes life gets busy, and you run out of your regular medication before you can see your primary care provider. The Starlight Medication Refill Program is here to help. We offer a safe, simple, and same-day way to get a short-term refill so you don’t have to miss important doses while waiting for your next appointment.

Our program focuses on low-risk maintenance medications commonly used for conditions like high blood pressure, diabetes, thyroid disorders, asthma, and more. This service is designed to bridge your care, not replace your regular provider, ensuring you stay on track without interruption. You can refill up to 5 of your medications without the need for a provider visit or leaving your home.

To protect your safety, we cannot refill certain medications, including:
- Controlled substances (e.g., opioids, benzodiazepines, stimulants)
- Narcotic or sedative medications
- Chronic pain medications (gabapentin, pregabalin, muscle relaxants)
- Fioricet, promethazine, and tricyclic antidepressants
- Weight loss or hormonal therapies
- Immunosuppressants, antipsychotics, mood stabilizers, warfarin
- Most injectables (except insulin and epinephrine)
Here’s what to expect:
- Fast intake: A brief questionnaire to verify your medication and safety information
- Clear guidance: If your medication isn’t eligible, we’ll let you know as soon as possible
- Short-term refill: Approved requests typically will receive a 14-30 day supply depending on medication to safely bridge care
- Professional oversight: Managed by experienced medical staff with your safety as our priority
Requirements:
- A valid address and a Colorado Pharmacy are required to get a refill
- A valid phone number capable of receiving SMS text
- A high-quality photo of your previous prescription label to verify your medication dosage and date of last prescription
- Once your information is entered and payment received, we will process your request by the end of the day
Fees
- The cost of this refill is $50 and is not covered by any insurance plan. This fee is to be paid after your case has been reviewed and prescription has been sent. If none of your scripts are eligible for refill you will not be charged for your request
You’ve come to the right place for a quick, dependable solution to keep your medications on track until you see your primary provider.

If you're ready, then lets get started!

Demographics
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Gender (Biological)*
Email*
example@example.com
Phone Number*
Please enter a valid phone number capable of receiving SMS textFormat: (000) 000-0000.
Home Address*

Street Address

Street Address Line 2

CityState

Zip Code

Pharmacy Information
Pharmacy Name*
Pharmacy Address*

Street Address

Street Address Line 2

CityState

Zip Code
Pharmacy Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
A valid Colorado Pharmacy is required to continue

Safety Screening
Do you have any known allergies to this medication(s) or similar medications?*
Has your prescribing provider recently changed any of your doses or advised stopping this medication(s)?*
Do you currently have a primary care provider or specialist managing this medication(s)?*
Have you had any new or worsening side effects since starting this medication(s)?*
Are you experiencing any of the following right now: Sucidal thoughts, severe chest pain or shortness of breath or a recent hospitalization related to your medication(s)?
Your situation requires a provider level assessment and cannot be refilled through this program. Please contact your Primary Care or a local urgent care for a refill

Consent & Acknowledgement
Starlight Medication Refill Program Service Agreement

Privacy Practices Notice
Starlight Health respects your privacy and protects your health information under federal HIPAA regulations. The information you provide will only be used to process your medication refill request, provide medical care, and meet legal requirements. We do not share your information with anyone outside of your care team unless required by law.

Consent to Care and Treatment
By signing below, you understand and agree to the following:

The Starlight Medication Refill Program provides short-term, temporary refills only.
This service does not replace ongoing care from your primary care provider or specialist.
A licensed medical professional will review your request and may deny or limit refills if unsafe or outside the scope of this program.
This service is limited to a maximum of 5 medications per visit.
Any medication on the restricted list, or those that are above standard safe ranges will be denied.

Financial Agreement
The fee for this program is $50 per visit, due at the time of service.
This service is not covered by insurance and will not be submitted to your insurance plan for reimbursement.
Prescription medication costs charged by your pharmacy are not included in this fee.
Payments will be charged only after our staff has determined your prescriptions are eligible for refill.

Service Agreement
The Starlight Medication Refill Program is an asynchronous service. This means you will complete your intake form and then select a time on our scheduling calendar for review, and may be asked to answer additional questions after that time.
Your case will not be reviewed until after you have scheduled a time and entered payment information.
During the scheduled time, a licensed medical professional will review your request and may reach out to you via secure text message if more information is needed.
You are expected to respond promptly to any messages. Delayed responses will cause your case to be postponed to the following business day.
If additional questions or safety concerns arise during review, your refill may be delayed or denied until proper information is provided or a safety review is conducted by our medical providers.
This service is for short-term continuity of care only. Patients should follow up with their regular provider for ongoing medication management.
I Agree to: Starlight Health's Privacy PracticesI Agree to: Starlight Health's Consent to Care & TreatmentI Agree to: Starlight Health's Financial AgreementI Agree to: Starlight Health's Service Agreement
You must agree to all to continue
Score
Should be Empty:

Starlight Medication Refill Form

Demographics

Pharmacy Information

Medication Request

Medication 2

Medication 3

Medication 4

Medication 5

Safety Screening

Consent & Acknowledgement