Medication Refill Request

Name

First NameLast Name

Date of Birth

Phone Number

Area CodePhone Number

E-mail

Prescriber Name

Medication(s) and dosages that you need refilled:

Have you checked with your pharmacy to see if you have additional prescriptions "on file" for this medication that can be filled? (see explanation below)

YesNonot applicable

Pharmacy Name

Pharmacy Address

When is your next SCHEDULED appointment with your provider?

Note to your Provider:

TERMS AND CONDITIONS of this request:

Submitting this form does not guarantee that your medication will be, or can be, refilled.

You will be notified by email if there are any problems with your request.

Your pharmacy will notify you when your prescription is ready to be picked up.

Prescription refills are usually taken care of at your scheduled appointments. We will not be able to provide refills if you have not been seen for appointments. Your account may be charged a $25 refill fee.

Very Important if you are taking medications (stimulants) for ADD/ADHD:

By law, stimulant medications cannot be refilled
Prescribers can provide 3 months of separate prescriptions that a pharmacy can keep on file to be filled in subsequent months
You will need to call your pharmacy and ask if there are additional prescriptions on file for your stimulant that can be filled.

Information regarding controlled substance medications (Benzodiazepines such as Ativan, Klonopin, and most ADD/ADHD Medications):

By law, early refills or replacement prescriptions cannot be provided for controlled substances
Because these medications entail significant risks to health and safety, we often check the NC Controlled Substance Database

Request a Medication Refill