Refill Request

Home Refill Request

The following is a medication refill request form. Controlled medications (examples: Adderall, Ritalin, Klonopin, Xanax) prescribed outside of scheduled appointments will be charged a $50 prescription refill fee. Please complete all sections and then hit the “Submit” button. Refills will be automatically denied if any section is missing.

Your Name

Date of Birth

Preferred Pharmacy (Please include address and phone number)

Medication being requested (e.g. Advil). Please include dose (e.g. 200 mg) and how you are taking the medication (e.g. twice a day)

Further comment/instructions (optional)

I understand that this is a refill request, and it does not mean that I will receive the requested medication. My doctor will carefully review the request and determine whether to approve it, deny it, or request a follow-up appointment.

Refill Request

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