Medication Refill Request

Medication Refill Request
This form is for controlled substances only (stimulants, benzodiazepines, sleep aids).

All other refill requests for routine medications should be initiated through your pharmacy's automated refill system.

Please allow up to 48 business hours to process your request. Requests received after 4 PM or on weekends will not be reviewed until the next business day.
Patient's Name:

First NameLast Name
Patient's Date of Birth:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Parent's Name (if a minor):

First NameLast Name
Phone Number if we have questions:
Please enter a valid phone number.Format: (000) 000-0000.

Prescription(s) Requested: