Prescription Refill Request Form

User Guide: Prescription Refill Request Form

Overview

This Prescription Refill Request Form allows you to conveniently request refills for your medications. The form is designed to be easy to use both online and in print format.

How to Use the Form

Filling Out the Form

1. Patient Information Section
   • Enter your full legal name (required)
   • Provide your date of birth (required)
   • Include your phone number (required)
   • Add your email address (optional)
   • Fill in your complete address
2. Pharmacy Information Section
   • Provide your preferred pharmacy's name
   • Include the pharmacy's phone number and address
   • This ensures your refills are sent to the correct location
3. Medication Request Section
   • For each medication, provide:
     • Medication name (required for first medication)
     • Strength (e.g., 500mg, 10mg)
     • Dosage instructions (how you take the medication)
     • Quantity needed
     • Number of refills requested
4. Additional Information Section
   • Include any questions for your pharmacist or doctor
   • Select your preferred contact method for follow-up
5. Signature Section
   • Provide your signature (required)
   • Enter the current date (required)

Buttons

• Print Form: Creates a printer-friendly version of your completed form
• Clear Form: Erases all entered information so you can start over

Tips for Success

• Complete all required fields (marked with *)
• Verify your pharmacy information is correct
• Provide accurate medication names and dosages
• Allow 48-72 hours for processing after submission
• Contact your pharmacy directly for urgent needs

Printing the Form

Click the "Print Form" button to generate a printable version. The printed version will:

• Remove unnecessary buttons
• Format optimally for paper
• Maintain all your entered information

Security Notes

• This form does not automatically submit data online
• For privacy, print and deliver the form directly to your pharmacy or healthcare provider
• Do not email the form without proper security measures

Troubleshooting

• If dates aren't displaying correctly, check your browser's date format settings
• If the print preview doesn't show all content, check your browser's print margins setting
• For best results, use an updated browser version

If you have any questions about your medications or this form, please contact your healthcare provider or pharmacist directly.