Prescription Refill Request
Please complete this form if you need a prescription refill in between appointments.
It is our policy to give enough medication and refill until next appointment. Patients in the practice are required to be seen for medication management on a monthly basis. It is patient’s responsibility to remain current with their appointment schedule in order to obtain enough medication on time. To minimize errors and for your safety, we discourage medication refills in between scheduled appointments and charge an administrative fee for this service.
Due to the necessity for communication on many levels, refilling medications through pharmacies can be a frustrating experience for both patients and staff. Therefore, pharmacy refill requests are disregarded.
It is of the utmost concern to us that we refill your medications in a timely manner. We request two business days for routine refill requests -- if your need is more urgent, please call our office (415.653.3100) or email Dr. Hariprasad AFTER filling out this form.
Date of Birth
Before requesting a refill between appointments, you will need to have scheduled a follow up appointment with the doctor within the next 2 weeks. If you do not have an appointment scheduled soon, please call and/or email
to set an appointment first. You can expect a refill with enough medication to make it comfortably to your next appointment.
Next appointment date
Please write "same pharmacy as last prescribed" or provide us with the pharmacy name, telephone number, address and zip code if using a different pharmacy.
We charge a fee for refills requested between visits to help offset the increased work this imposes as well as to encourage patients to ensure that they have sufficient medication prescribed to them at each visit. Controlled substances require much more labor as they require additional documentation and searches in state databases. If this fee would cause you a hardship or if you feel there is a circumstance that warrants an exception, do feel free to indicate accordingly and just leave us a note explaining in the comments section on the next screen for consideration.
($25 FEE) - One or more requested non-controlled prescriptions
($75 FEE) - One or more of my requests is a controlled substance (stimulants, benzodiazepines)
(NO CHARGE) Doctor forgot to prescribe/made an error
(NO CHARGE) This fee would cause financial hardship
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