Routine Refill Request

Routine Refill Request

Patient-facing refill request form. Please complete the required acknowledgments and only use this form for routine refills.
BEFORE YOU START: This form is for continuing your current plan exactly as-is — same medications, same doses.
Please submit refill requests through this form only. Do not also send a text or portal message requesting the same refill. Duplicate requests cause delays because each request must be reviewed separately.
BEFORE SUBMITTING THIS FORM

Use this form only for a routine refill of your current medication at the same dose.

• If you are having a side effect or concern about your medication, do not submit this form. Please message your provider in the portal.

• If you would like your treatment or dose re-evaluated, do not submit this form. Go to www.menopauselouisiana.com/track and select “Refill.”

For routine refills, this form is the only request you need to send. Please do not also send a text or portal message about the same refill, as duplicate requests may delay processing. We’ll contact you if we need any additional information.
ACKNOWLEDGMENT
Patient Information
Patient Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Routine Refill Request Acknowledgments
I understand that this form is for routine refill requests only and should not be used for urgent or emergency needs. For a medical emergency or urgent concern, I will seek care through the emergency room or an urgent care center. For questions or concerns related to my hormone treatment, medications prescribed by The Menopause Clinic, side effects, symptoms, or changes in my treatment, I will message my provider through the patient portal for the quickest response.
Medication Needing Refill
Medication Needing Refill

Other
Medication Availability: Is this request because your pharmacy told you your medication is out of stock?
If you still have refills, please:
1. Review current medication and pharmacy options by clicking HERE
2. Find a pharmacy with your medication in stock.
3. Ask the new pharmacy to transfer the prescription from your current pharmacy.
4. If the pharmacy cannot transfer it, continue below and we’ll help.
If you still have refills, transferring your existing prescription is usually the fastest option and helps prevent duplicate prescriptions or confusion between pharmacies.
Were you able to request a pharmacy-to-pharmacy transfer?
Great! Your pharmacy can complete the transfer using your existing prescription, so you do not need to request a new prescription at this time.
Current dose and how taken
During current supply shortages, local independent pharmacies may have better availability than larger chain or big-box pharmacies.
Pharmacy name and address
Pharmacy name and city/location
If you are not sure your treatment is working well, your symptoms are not where you want them to be, or you would like your provider to review your treatment plan, complete the symptom tracker at www.menopauselouisiana.com/track and select Provider Review.
I understand and will let my provider know if any of the following applies to me: If I have a uterus and use progesterone or another progestin for uterine protection, I will tell my provider if I stop it, change it, or am no longer taking it as prescribed. If I use an IUD for uterine protection, I will tell my provider if it has been removed or if it is more than 5 years old
Are you taking your medications exactly as instructed by The Menopause Clinic?
What has been different?
Major Health Changes
Have there been any major health changes?
Please describe the major health changes
Testosterone Acknowledgments
Have you completed or scheduled your required testosterone visit?

I have not completed an in-person visit for the purpose of a testosterone refill within the last month. I understand that I will need to schedule and complete an in-person visit before my testosterone refill can be provided. I can schedule my visit and review all requirements for continuing testosterone here: https://www.menopauselouisiana.com/continuing-testosterone or go to the member hub anytime at www.menopauselouisiana.com and click on testosterone for the requirements.
Should be Empty:

Routine Refill Request

Patient Information

Routine Refill Request Acknowledgments

Medication Needing Refill

Major Health Changes

Testosterone Acknowledgments