Today's Date:
Person completing form:
E-mail:
Which office location do you use?
Who prescribes your medication?
Patient's Name:
Patient's Date of Birth:
Last appointment date:
Next appointment date:
Medications:
Medication #1 (exact medication name on bottle)
Dosage:
Current Directions (e.g. -- Take 1 tablet each morning):
Prescription requested:
30-day refill
60-day refill
90-day refill
Medication #2 (exact medication name on bottle)
Dosage:
Current Directions (e.g. -- Take 1 tablet each morning):
Prescription requested:
30-day refill
60-day refill
90-day refill
Medication #3 (exact medication name on bottle)
Dosage:
Current Directions (e.g. -- Take 1 tablet each morning):
Prescription requested:
30-day refill
60-day refill
90-day refill
Requesting prescription to be:
Sent electronically to pharmacy*
Mailed
Left at reception for pick-up
*All medications can now be sent electronically to most pharmacies and this is the preferred method for renewing prescriptions.
If to be mailed, mailing address:
If to be sent electronically, Pharmacy Name:
City Where Pharmacy Located (and street if more than 1 in town):