Prescription Refill Request

Prescription Refill Request

The Prescription Refill Request form is for the convenience of our current patients at Mindfully Psychiatry, LLC.
Terms and Conditions:
- Before submitting this form, please check with your pharmacy to determine if you have any refills remaining on your prescription.
- Submitting this form does not guarantee prescription authorization. Please only submit this form if you are a current patient of Mindfully Psychiatry. Repeated medication refill requests will not be authorized.
- Fill in the form clearly with the exact name of the medication, dose, and pharmacy information.
- Only use this form for medication refill requests. Do not use this for other purposes. For all other requests, please contact us at 844-533-0315
- It may take up to 72 hours to process your refill request.
- Please check with your pharmacy about the status of your refill after 24-72 hours after submitting this form. Do not call the office to check the status of your refill request. We will contact you if your prescription will not be refilled.
Emergency Disclaimer :

This form is not monitored for emergencies and should not be used for urgent or crisis situations. If you are experiencing a medical or mental health emergency: Call 911 or go to the nearest emergency room. You can also contact the 988 Suicide & Crisis Lifeline by calling or texting 988. Your safety is our priority — please seek immediate help if you are in crisis.
Client Information
Client Name*

First NameLast Name
Client Date of Birth*

MonthDayYear
Date
Client Email
example@example.com
Cell Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Phone Number - Other
Please enter a valid phone number.Format: (000) 000-0000.
Mindfully Provider Email
The minfdully email format is your providers name - first.last@mindfully.com
Provider Name
If you cannot remember your providers name select "I am not sure" and staff will make sure it gets to the correct provider.

Please List Medications Needed Below:*

Rows	Medication Name	Dosage	Additional Info
1
2
3
4
5
6
7
8
9
10

Pharmacy Information
Pharmacy Name *
Pharmacy Phone Number *
Please enter a valid phone number.Format: (000) 000-0000.
Pharmacy Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
By selecting this box you agree to the terms of form submission and that you understand that submitting this form does not guarantee a refill authorization, and if authorized may take up to 72 hours to be submitted to your pharmacy of choice.
YesNo
Name of Authorized Representative:*

First NameLast Name
Relationship to the Client*
Signature
Should be Empty:

Prescription Refill Request

Client Information

Pharmacy Information