Prescription Refill Request Form- Diana Boutte clients
If you are a current patient of one of our Prescribers and need a prescription(s) refill, please first check with your pharmacy to ensure you've exhausted any built-in refills that may have been included last time.

If you have additional questions, please contact us at: (804) 789-9405.  All medication refill requests should be requested through this form.


Refills will only be sent if a follow-up appointment has been scheduled and the patient is up to date on visits.

 You may schedule one of two ways:

  • 1. You may schedule an appointment through portal access (provided by your provider).

2. You may also contact us at (804) 789-9405

Please note, prescription refills may take anywhere between 24- 48 hours from the time of request; also, we are not available on weekends or holidays.  We do not take prescription requests after 11am on Fridays. 

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*
Name of Patient: *
Email Address: *
Phone Number: *
Who is making this request? If not the Patient, what is your name and relationship? (Parent/Caregiver, etc.) If Patient is making request, simply list "self."  *
Patient DOB: *
MM
/
DD
/
YYYY
Pharmacy Name: *
Pharmacy Address: 
(If it is the one we have on file for you, just say "on file".  If it is a new pharmacy, let us know that address) 
 *
Name of Medication & Dosage:  *
How many days of medication do you have left? *
Additional Medications & Dosage:
How many days of medication do you have left?
Date of Next Scheduled Appointment: 
(If you don't have one scheduled yet, you can let us know that) 
 *
Date of LAST Appointment: 
Name of your Prescriber: *
Is there anything else you'd like us to know?
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