Prescrition Refill Request Form

Please complete this form in full to request a prescription refill. Your responses help us ensure safe and appropriate medication management.

1. Patient Information

Full Name

Date of Birth

Address

City

State

ZIP

Phone

Preferred Contact Phone SMS Email

Email Address

2. Prescription Information

Medication Name

Strength (e.g., 500 mg)

Form (e.g., tablet, gel, rinse)

Current Dosage & Frequency

Original Prescription Date

Prescription Number (if known)

Pharmacy Name

Pharmacy Phone

Reason for Refill Request

5. Follow‑Up & Care Plan

Do you require a telehealth consultation before approval?

Yes No

Schedule a follow‑up teledentistry appointment?

Yes No

Preferred time Morning Afternoon Evening

Questions or concerns about medication or treatment plan

6. Authorization & Signature

The practice will review my request and may contact me for further assessment.
Approval of a refill request is at the discretion of the prescribing provider.
If clinical evaluation is required, I may be asked to schedule a virtual or in‑office visit.

I certify the information is accurate and complete.

Patient Signature

Date

If signed by guardian/representative

Name

Relationship to Patient

Representative Signature

Date

Thank you for your request. We aim to process refill requests within 2 business days.

Teledentistry Prescription Refill Request Form

1. Patient Information

2. Prescription Information

3. Symptom & Oral Health Screening

4. Medication Use & Compliance

5. Follow‑Up & Care Plan

6. Authorization & Signature

If signed by guardian/representative

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