Medication Refill Request

This MEDICATION REFILL REQUEST FORM is for the convenience of our current patients only.

Please Note:

• It is our office policy that medication refills will only be provided at regularly scheduled follow up visits.
• This form is intended for urgent medication refill requests only such as situations in which a patient will run out of medication shortly before a scheduled office visit or situations in which an emergency prevents a patient from attending a scheduled office visit.
• Medication refills will not be authorized in the following situations:
  • You do not currently have a follow up visit scheduled
  • You have not been seen for an office visit for an extended period of time
  • You often cancel or miss scheduled appointments
  • You have an outstanding balance for services received

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Patient Name *

First

Last

Patient Email *

Pharmacy Name *

Pharmacy Phone Number *

Medication Name *

Dosage taken per day

Medication Name #2 (optional)

Dosage taken per day

Message (ONLY IF NECESSARY)

This area is reserved. It is ONLY NECESSARY for specific prescription details and refill information. It is not for clinical questions or any other comments and is NOT a way to reach Dr. McGinty. Instead, call the office and leave a confidential message.

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