Medication Refill Request Form

Please fill out the following form in its entirety (all fields are required to complete). Please be sure to provide contact information where you can be reached in case there are any questions regarding your request. When you are finished, please click the Submit button.

  • If you have not seen the psychiatrist or psychiatric nurse practitioner in the last 6 months your refill request will be denied.
  • Please note that past due balances and missed appointments may delay your refills.
  • Refills can take up to 72 hours to process so please plan accordingly (does not include weekends and holidays). Please do not call the nurses line unless it is has been more than 72 hours.
  • All medications are sent electronically directly to the pharmacy. This includes controlled substances.

    Refills are routinely issued Monday through Friday between the hours of 9 am and 5 pm. Requests submitted after 3pm on Friday, all day Saturday, Sunday and holidays will be handled on the next business day.