Prescription refill request

Request a medication refill without phone calls: prescription details, pharmacy, and urgency.

Use this template

Prescription refill

Patient name

First Name

Last Name

Date of birth

Phone number

Medication to refill

Dose and directions

Prescribing physician

How many days of medication do you have left?

Preferred pharmacy

Has anything changed in your health or other medications since the last prescription?

Yes No

What changed?

Urgency

Normal — I can wait 1–2 days Soon — less than 3 days left I've run out