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