Refill Request

This form is only for patients who already have an active prescription refill plan in place with their clinician.

Name

First

Last

(same email used to login to your portal account)

By your the

Date of Birth

By continuing, you acknowledge that misuse of this form will delay access to your care.

I acknowledge and understand

If you do not have a current refill plan, your request will not be reviewed and will be automatically disregarded. You will be required to schedule an appointment with your provider before any medications are issued.

Name of Medication(s)

If you are requesting more than one medication, please list them all here and separate each name with a comma. One form per patient only.

Preferred Pharmacy

Please enter your preferred pharmacy’s name, full address, and phone number. Be sure to confirm they have your medication in stock before submitting this request, as availability issues may delay your refill.

Additional Notes

Please Read and Acknowledge the Following:

I understand that prescription refill requests may take up to 5 business days to process. I acknowledge that it is my responsibility to plan accordingly and that submitting this request does not guarantee approval.
I confirm that I have checked my pharmacy’s stock and understand that availability issues may delay my refill. I acknowledge that it is my responsibility to verify availability in advance, and that any delays caused by stock issues are not the responsibility of the clinic.