Medication Refill Request

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Please submit a refill request through your pharmacy and allow three business days to process
before completing this form. We do not refill prescriptions by the phone, voicemail or email. All medication refills are at prescriber discretion per the agreed upon treatment plan and intake.

Email *

Safety and Emergency Contacts

Prescriptions must be taken as prescribed and per the dosage, frequency, and method prescribed. We do not provide emergency medications, this includes lost or stolen medications. Medications should only be taken by the individual they are prescribed to.

Please reach out to your local urgent care or hospital if there is a mental health emergency. If you are out before the next refill date, you must see the provider for another appointment before additional medications are considered.

Spokane Region Mental Health Crisis Line: 1-877-266-1818
SAMHSA's National Helpline – 1-800-662-HELP
All other emergencies please call 911

First & Last Name *

Date of Birth *

YYYY

Phone Number *

Date of last appointment (must have been seen in the last 90 days)- If you're not sure check your portal login.

YYYY

Name of Medication *

Dosage *

Frequency *

Pharmacy Name *

Pharmacy Address *

Questions and Comments

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