Mental Health Medication Refill Request Form

Please fill out the following form in its entirety. Please be sure to provide contact information where you can be reached in case there are any questions regarding your request.

When you are finished, please click the Submit button.

Name(Required)

Patient Phone*(Required)

Patient Email*(Required)

Medication Name 1*(Required)

Medication Name 2

Medication Name 3

Pharmacy Name*(Required)

Pharmacy Phone*(Required)

Additional Information

Disclaimer(Required)

Disclaimer*

If you have not seen the psychiatrist or psychiatric nurse practitioner in the last six months, your refill request will be denied. Please note that past due balances and missed appointments will delay your refills. Refills can take up to 72 hours to process, so please plan accordingly (this does not include weekends and holidays). Please do not call the nurse’s line unless it has been more than 72 hours. All medications are sent electronically directly to the pharmacy. This includes controlled substances. Refills are routinely issued Monday through Thursday between the hours of 9:00am and 5:00pm.

Name

This field is for validation purposes and should be left unchanged.