Clearwave Med Refill Request Form

1

Is this request for a controlled substance medication (e.g., Adderall, Vyvanse, Ritalin, Klonopin, Xanax)* This field is required.This medication request form is for controlled substances ONLY.

YESNO

2

This form is for Controlled Substances Only

Please contact your pharmacy directly for non-controlled substances for quickest turnaround.

3

Name* This field is required.

First Name

Last Name

4

Date of Birth* This field is required.

Date

6

Medication Refill Request Details (Medication Name, Dose, Quantity, Reason for Refill, Preferred Pharmacy)