Medication Refill Request

Medication Refill Request
Medication Refill Request form is for the convenience of our current patients. This helps minimize phone calls and allows our office staff to attend to your needs quickly and efficiently.

Please note, if you do not wish to submit protected health infromation you should call the office and address your request with a staff member. This form is intended to address your refill request quickly and calling into the office can increase turn around time to address.

Please be advised that any refill request completed as a result of a missed appointment or lost medication there will be an administrative fee of $50. To avoid this fee you can schedule with your provider and address the refill at the time of your next appointment.

Repeated medication refill requests will not be authorized. Additionally, patients who have not been seen in the office for a long time or who frequently miss their appointments may not be provided with refills.

Fill in the form completely including the accurate pharmacy infromation. It may take up to 72 hours to complete a refill request or longer if during weekends and holidays. Please do not call the office to check on the status of your request.

Please call your pharmacy to see if they've received your presrciption. You should have more than 3 days of medication left at home when you request a refill.
Please Read The Following

Check with your pharmacy if you have any refills left on your last prescription or if their are any new prescriptions under your name before sending in this request. If there is refills or new prescriptions at the pharamacy we will not address this refill request.
Patient Information
Patient Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date of birth
Patient Email*
example@example.com
Patient Phone Number*
I agree to allow Journey Healthcare to contact me?

YesNo
By submitting this form via this web portal, you acknowledge and accept that risks of communicating your health information via this unencrypted email and electronic messaging and wish to continue despite those risks. By clicking "Yes, I want to submit this form" you agree to hold Journey Healthcare LLC harmless for unauthorized use, disclosure, or access of your protected health information sent via this electronic means.*

Yes
Journey Healthcare Location
Date of Next Appointment*

MonthDayYear
Date
Pharmacy Information
Pharmacy Name:*
Pharmacy Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Pharmacy Phone Number*
Please enter a valid phone number.
Pharmacy Fax Numer
Please enter a valid phone number.
Medications Needed
Prescription written by:*
Medication Name*
Dosage taken per day*
Medication Name
Dosage taken per day
Medication Name
Dosage taken per day
Please provide context as to why you are requesting this medication refill:*
Should be Empty:

Medication Refill Request

Please Read The Following

Patient Information

Pharmacy Information

Medications Needed