• Medication Refill & Continuity Care Intake

    Complete this form to request medication refills and provide your health information.

  • Basic Information

  • Format: (000) 000-0000.
  • Thank You for Your Interest

    SimoneRx currently provides telehealth services only to residents of Georgia, California, and New Hampshire.

    Your contact information will be recorded, and our care team will reach out to you as soon as we expand to your state. Please complete this form below to join your waitlist.
  • Preferred Method of Communication*

  • How Many Prescriptions?

    Select how many medications you need refilled. Each will be entered separately. Pricing tier is determined by prescription count.
  • How many prescriptions do you need refilled?*

  • Prescription Details — #1

  • How Often Do You Take It?*
  • How Long Have You Been Taking This?*
  • Are You Currently Out of This Medication?*
  • Previously Prescribed By*

  • Prescription Details — #2

  • How Often Do You Take It?*
  • How Long Have You Been Taking This?*
  • Are You Currently Out of This Medication?*
  • Previously Prescribed By*

  • Prescription Details — #3

  • How Often Do You Take It?*
  • How Long Have You Been Taking This?*
  • Are You Currently Out of This Medication?*
  • Previously Prescribed By*

  • Pharmacy Information

    Your Preferred Pharmacy
  • Format: (000) 000-0000.
  • Do We Have Your Info on File with This Pharmacy?*
  • Medical History
  • Current Conditions
  • Please check all that apply (you may select more than one)*
  • Allergies
  • Do you have any known drug allergies?*
  • Current Medications

  • Safety Questions

    Recent Medical Events
  • Have you been hospitalized in the past 6 months?*
  • Have you had an emergency-room visit in the past 6 months?*
  • Have you had any new or worsening symptoms recently?*

  • Additional Information

    A valid Driver's License or Photo ID is required. Other uploads on this page are optional — add them if you have them (lab results, insurance card, prior prescriptions).
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  • Upload a File
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  • Upload a File
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  • Consent & Acknowledgment

    Please Review and Agree
  • Please check ALL boxes to acknowledge and agree*
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