Please use this form to request your prescription refill(s). We are unable to send in refills of controlled substances outside of appointment times, and furthermore cannot guarantee that your pharmacy will have the medicine in stock. Please make sure you’ve downloaded your pharmacy’s app or are otherwise in touch with them, as we’re no longer able to follow up due on each submission due to the volume of requests. Thank you for your patience and cooperation.

Name

First Name

Last Name

Email

Name of Medication(s)

Are any of the medications listed above classified as controlled substances?

We are unable to refill controlled substances without an in person appointment.

Yes, I am requesting to refill a controlled substance.

No, I am not requesting to refill a controlled substance.

Refill needed by:

MM

DD

YYYY

Pharmacy Information

Pharmacy Location

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Pharmacy Phone Number

(###)

###

####

Notes (Optional)

Please be aware that all prescription refills are subject to review by the practice. We will notify you should you need to come in for an in-person appointment.