Refill Request

1
Welcome!

We use this form to collect information to help us process your refill request quickly and convieniently. Please note this form is for refills only. If you are experiencing a medicaiton concern or are wanting to to make changes to your medicaiton please contact our office by phone.

This form is HIPPA compliant; any information entered into this form is stored and saved securely and will be used for the purpose of evaluating your medication request.

Please note that a $15.00 medication refill fee for evaluation and management of prescriptions via telephone, text, portal, or email due to missed, cancelled, or unscheduled follow up appointments may be billed to your patinet account. This fee is not covered by insurance.

This form inbox is monitered deligently during our business hours (Monday-Thursday 8:00am-4:00pm and Friday from 8:00am-12:00pm; excluding holidays). If your request is made outside our normal buisness hours it will be addressed on the following buisness day. If your request is urgent please call our office number 334-954-6010 and leave a voicemail with detailed information regarding your request.

To proceed in completing this form click the next button below.
2
Let's get started! Please enter your name.* This field is required.
First Name
Last Name
3
Please verify your date of birth.* This field is required.
Date
Year
Month
Day
4
How can we help you? Which medication is in need of a refill?* This field is required.Please specify the medication name and dosage.
5
How many doses of this medication do you have left? * This field is required.
6
How are you currently taking this medication?* This field is required.
ex: once at bedtime, twice a day, 1-3 as needed
7
What pharmacy do you use?
8
Have you called your pharmacy to verify there is no medication available for pick up?* This field is required.
YESNO
9
If you have not called your pharmacy please do call them to see if there is medication available for pick up even if it says no refills on the bottle of your medicine. Often when a 90 day supply of medication is called in the pharmacist will only fill 30 days at a time for insurance purposes. There also could be an unfilled prescription waiting for you at the pharmacy.

Once you have called your pharmacy and verified there is no medicaiton available to you you can resume this form where you left off.
10
Who is your medicating provider?* This field is required.If you have seen multiple providers at our practice please select the provider with whom you had your last appointment
Dr. Amanda Williams
Dr. Will Rutland
Rachel Liner, CMHNP
Thomas Earnest, CMHNP
11
Do you have a follow up appointment scheduled?* This field is required.
YESNO
12
When is your next scheduled appointment?
Date
Year
Month
Day
13
It is essiential you are evaluated regularly when taking medications. For this reason, please be advised you may need a follow up appointment scheudled in order for your provider to call in your medication. Someone from our office will give you a call regarding scheduleing if that is the case.

You may proceed in completing this form by clicking the next button below.
14
Please list any concerns, comments, or questions you have for our clinical staff in the field below.
Huge
Large
Normal
Small
Ok
Ok
15
How would you like to hear back from our office regarding this medication request?
Phone Call
Text
Email
Should be Empty: