Rx Refills (Correspondence Folder + To Do "Spruce")

Prescription Refill Request
Date

MonthDayYear
Date
Patient Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Person completing form*

PatientParent of Minor/Legal GuardianMedical Power of Attorney
Medication Name(s) for Refill Request*
Pharmacy Name and Location*
REFILL GUIDELINES:

All refills require at least yearly in-office visits. If your condition is chronic and well-controlled with topical medications alone, you may feel comfortable having your primary care physician refill these medications long-term.

Some systemic medications require 3-6 month follow-up and cannot be refilled if the patient has not been re-evaluated.

Please allow 48 hours for our office to address your refill request.

COMPOUNDED MEDICATIONS:

If you are prescribed a specialty compound medication, these are sent to a specialty compounding pharmacy such as Medrock Pharmacy.
Should be Empty:

Prescription Refill Request