Rx Refill Request

Rx Refill Request

Use the form below to message your PMHNP to request an Rx refill, however, most refills can be completed by contacting your pharmacy first.
Client's Name*

First NameLast Name
Client's Email Address*
Mobile Phone Number*
Provider*
Provider's Email
Prescription to refill*
Are your prescription(s) considered a controlled substance?

YesNoI don't know
Refills of controlled substances will most often require a session with your provider. You can continue to complete this form; however, after completing this form, you can take the next step and book a follow-up session with your provider in the client portal.

Click here to access the client portal.

Common controlled substances:
- Adderall
- Vyvansel
- Methylphenidate
- Lisdexamfetamine
- Xanax
- Klonopin
- Alprazolam
- Clonazepam
- Ambien
- Zolpidem
Pharmacy*
Pharmacy Address/Location*
Should be Empty: