Medication Refill Request Form
For routine refills only. Processing may take 3–5 business days. Not for emergencies, urgent symptoms, or medication changes.
Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Email
*
example@example.com
Next Appointment Date
*
-
Month
-
Day
Year
Date
List all medications you are requesting to refill
*
Rows
Medication Name
Current Dose (e.g., 50 mg)
Frequency
Medication 1
Once daily
Twice daily (BID)
Three times daily (TID)
Four times daily (QID)
As needed (PRN)
Weekly
Other
Medication 2
Once daily
Twice daily (BID)
Three times daily (TID)
Four times daily (QID)
As needed (PRN)
Weekly
Other
Medication 3
Once daily
Twice daily (BID)
Three times daily (TID)
Four times daily (QID)
As needed (PRN)
Weekly
Other
Medication 4
Once daily
Twice daily (BID)
Three times daily (TID)
Four times daily (QID)
As needed (PRN)
Weekly
Other
Medication 5
Once daily
Twice daily (BID)
Three times daily (TID)
Four times daily (QID)
As needed (PRN)
Weekly
Other
Medication 6
Once daily
Twice daily (BID)
Three times daily (TID)
Four times daily (QID)
As needed (PRN)
Weekly
Other
Pharmacy name and location
*
Date you will run out (earliest if multiple)
*
-
Month
-
Day
Year
Date
Have you missed any doses?
*
No
Yes
If yes, please briefly explain
Have you experienced any side effects?
*
No
Yes
If yes, please briefly explain
Important Acknowledgments
*
Patients need to be seen every month for controlled substances and every 3 months for other medications
Please check all that apply
*
I am requesting a controlled medication
I am not requesting a controlled medication
Important Acknowledgments (check all)
*
I understand processing may take 3–5 business days
I understand controlled substances cannot be refilled early
I understand refills follow my last documented plan and I need to follow up every 1-3 months
I understand medication changes require an appointment
I confirm this request is accurate
For Controlled Medications Only
Please check all that apply:
*
No lost/stolen medication
No dose changes without provider instruction
I understand early refill requests may be denied
Submission Statement
Submitting this form does not guarantee a refill.
*
Acknowledge
Anything else the provider should know? (1–2 sentences only)
Submit Request
Should be Empty: