Prescription Refill Request Form
This prescription refill request form is for our current patients only.

Repeated medication refill requests will not be authorized. Additionally, patients who have not been seen in the office for an extended period of time or who have excessive unpaid balances may not be provided with refills without being seen. Our office will contact you if your request has been denied.

Check with your pharmacy if you have any refills left on your last prescription BEFORE sending this request. Please allow for a minimum of 24 hours Monday - Thursday and 72 hours Friday - Sunday for your request to be reviewed and handled appropriately.

Please check with your pharmacy about the status of your prescription prior to contacting our office. Someone from our office will contact you if there is a reason your medication will not be called in.
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Important Note
Please fill in the form clearly with the exact name of the medication and dose (found on your medication bottle) in addition to your pharmacy information.

Please allow time for our office staff to process this request before checking status with our office or pharmacy.

To assure that you do not run out of your medications, please request a refill at least a week in advance of running out of medication.

Contact our office if you have any questions.
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This form was created inside of Summerville Psychiatric Associates.