Medication Refill Request

/Medication Refill Request
Medication Refill Request2020-01-28T15:08:54+00:00

Medication Refill Request Form

This MEDICATION REFILL REQUEST FORM is for the convenience of our current patients only.

Please Note:

  • It is our office’s policy that medication refills will only be provided at regularly scheduled psychiatric follow up visits.
  • This form is intended for urgent medication refill requests only such as situations in which a patient will run out of medication shortly before a scheduled office visit or situations in which an emergency prevents a patient from attending a scheduled office visit.
  • Medication refills will not be authorized in the following situations:
    • You do not currently have a psychiatric follow up visit scheduled with one of our psychiatric providers
    • You have not been seen for an office visit by one of our psychiatric providers for an extended period of time
    • You often cancel or miss scheduled appointments at our practice
    • You have an outstanding balance for services received at our practice.

Please Read Before Submitting Your Request:

  • Please contact your pharmacy to make sure that you do not have any refills remaining on the last prescription(s) provided by our office.
  • There is a $25 fee for submission of medication refills outside of a scheduled office visit.
  • Our administrative office is available to respond to medication refill requests during regular office hours, Monday through Friday from 8:45 a.m. to 5:00 p.m.  The length of time needed to respond to your request will depend upon factors such as the office hours of your psychiatric provider and the day of the week you submit your request (we do not respond to requests on weekends or holidays).
    • We will respond to your request as quickly as possible, but please be aware that it may take up to 2 to 3 business days before you receive a reply.

Directions:

Please fill in the form below clearly and completely and include all requested information.  Omitting required information will cause a delay in our office responding to your request. Please DO NOT call the office to check the status of your request. We will respond to your request as quickly as possible, and you will receive a reply from our office.

Patient Info


First Name*

Last Name*

Patient Email*

Date of Birth*

Patient Main Phone Number*

Date of Next Appointment*

Pharmacy Info


Pharmacy Name*

Pharmacy Phone Number*

Medications Needed


Name of Your Psychiatric Provider (please select from drop down menu):*

Medication Name*

Dosage taken per day*

Second Medication Name (if applicable)

Dosage taken per day

Third Medication Name (if applicable)

Dosage taken per day

Additional Comments