Prescription Refill Request Form

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Prescription Refill Request Form

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 would like additional information, please contact us at: (210) 366-3700

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

You may schedule one of three ways.

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

2. You may visit our website "Schedule an appointment" page: Mind Works Website

3. Lastly, you may also contact us at (210) 366-3700

Please note, prescription refills may take anywhere between 1 business day, up to, at times, 3 business days if prior authorizations or detailed review is necessary; also, we are not available on weekends or holidays.

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

Email *

Name of Parent/Caregiver completing Request: *

Phone number

(Do not include dashes - ex. 2105555555)

Name of Patient: *

Patient DOB: *

YYYY

Pharmacy Name: *

Pharmacy Address: *

Pharmacy Phone number:

(Do not include dashes - ex. 2105555555)

Name of Medication: *

Dosage: *

Date of Next Scheduled Appointment: *

YYYY

Select your Provider: *

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