formisoft
Medication Refill Request Form
Registration

Medication Refill Request Form

2 pages•14 fields•HIPAA-ready
Get startedBrowse all templates

Form preview

formisoft.com/f/medication-refill
Medication Refill Request Form
Patient Full Name
Date of Birth
Phone Number
Medication Name
Dosage and Frequency
Prescribing Provider
Preferred Pharmacy
Pharmacy Phone Number
Any Side Effects Experienced
Side Effect Details
Additional Notes
Submit
Use this template

The Medication Refill Request Form gives patients a convenient way to request prescription refills without calling the office. Patients provide their medication details, preferred pharmacy, and any relevant updates about side effects or changes in their condition. This structured approach ensures your clinical team has all the information needed to process refills efficiently and safely.

The form captures critical safety information including the medication name, dosage, prescribing provider, and the number of remaining refills. Patients can flag any adverse reactions, request dosage adjustments, or note changes in their symptoms. Built-in fields for pharmacy selection and contact information enable your staff to send prescriptions directly without additional follow-up.

Ideal for primary care practices, psychiatry offices, pain management clinics, and any practice that manages ongoing prescriptions. This form significantly reduces incoming phone calls related to refill requests and creates a documented trail for every prescription renewal, supporting both efficiency and compliance.

What's included

  • Patient identification and contact information
  • Medication name, dosage, and frequency details
  • Prescribing provider and last refill date
  • Preferred pharmacy name and contact
  • Side effect and symptom change reporting
  • Automated notification to clinical staff for review
  • Structured medication list with dosage and frequency tracking

Who uses this template

  • Routine prescription refills for chronic conditions
  • Psychiatry and behavioral health medication management
  • Pain management prescription renewal requests
  • After-hours refill request submission

All form fields

11 fields across 2 pages. Customize any field after signing up.

Patient Full NameText
Date of BirthDate
Phone NumberPhone
Medication NameMedications
Dosage and FrequencyText
Prescribing ProviderText
Preferred PharmacyText
Pharmacy Phone NumberPhone
Any Side Effects ExperiencedMultiple Choice
Side Effect DetailsLong Text
Additional NotesLong Text

Use this template

Sign up and start customizing the Medication Refill Request Form for your practice. 30-day money-back guarantee.

Get startedBrowse all templates

$79.99/mo · Cancel anytime · HIPAA compliant

Related templates

Medication Reconciliation Form
Patient Information
Prescription Medications
Over-the-Counter Medications
Vitamins & Supplements
Medication Allergies
Medical History

Medication Reconciliation Form

Structured medication list form with dosage, frequency, prescribing physician, pharmacy information, and adherence assessment. Essential for transitions of care and preventing medication errors.

1 page•8 fields
Advance Directive Form
Patient Full Name
Date of Birth
Healthcare Proxy Name
Proxy Phone Number
Proxy Relationship
Registration

Advance Directive Form

Document patient advance directive preferences including healthcare proxy designation, living will provisions, and end-of-life care wishes.

3 pages•16 fields
Appointment Request Form
Patient Full Name
Date of Birth
Phone Number
Email Address
New or Returning Patient
Registration

Appointment Request Form

Let patients request appointments online by specifying their preferred dates, times, providers, and reason for visit to streamline your scheduling workflow.

2 pages•13 fields