Medication Refill Request Form
Request a prescription refill securely. For urgent needs or emergencies, please contact your provider directly. Processing may take 1–3 business days.
Patient Information
Please provide your details so we can verify your identity and contact you regarding your request.
Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number (mobile preferred)
*
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred Contact Method
*
Phone
Email
SMS/Text Message
Email Address
*
example@example.com
Prescribing Provider / Clinic Details
Tell us who prescribed your medication and clinic location.
Prescribing Provider Name
*
Clinic or Practice Location (if multiple locations)
Medication Details
List each medication you need refilled. Click 'Add another medication' to request more than one.
Medication(s) to Refill: (For each medication, provide: Name, Dosage/Strength, Form, How often you take it, Quantity requested, Prescription number (if available), Is this urgent?)
Pharmacy Information
Let us know where to send your prescription.
I would like to change my pharmacy for this refill
*
No, use pharmacy on file
Yes, I want to use a new pharmacy
Pharmacy Name
*
Pharmacy Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Pharmacy Address
*
Clinical & Safety Questions
Your safety is important. Please answer the following.
Have there been any changes in your health since your last visit?
*
Yes
No
If yes, please describe the changes
Have you experienced any side effects from this medication?
*
Yes
No
If yes, please describe the side effects
Are you pregnant, breastfeeding, or planning pregnancy?
*
Yes
No
Not applicable
Timing & Availability
Let us know when you need your refill.
When do you need this refill by?
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Consent & Acknowledgements
Please review and confirm the following before submitting your request.
Consent and Acknowledgements
*
I confirm that I am the patient or legally authorized to request this refill.
I understand that my request is subject to provider approval and may require an appointment.
I consent to being contacted about this refill request.
Is it okay to substitute with a generic equivalent if allowed?
*
Yes
No
Your privacy is important to us. Please review our
Privacy Policy / HIPAA Notice
.
Electronic Signature (type or draw)
*
Date of Submission
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Thank you for your request! Our team will review your submission and contact you within 1–3 business days. For urgent needs or emergencies, please call your provider directly or visit the nearest emergency facility.
Submit Request
Submit Request
Should be Empty: