Prescription Refill Request Template

Patients use this form to request a prescription refill and share their medication, dose, pharmacy, contact details, date of birth, and symptom changes with their care team.

Use this template free

When to use it

• A patient needs a routine medication refill.
• A clinic wants to collect the preferred pharmacy and current dose.
• A care team needs to ask whether symptoms have changed before reviewing a refill request.

What it asks

1. Your name
2. Phone number
3. Email address
4. Medication
5. Dose
6. Pharmacy
7. Date of birth
8. Have your symptoms changed?

Why it should be encrypted

Medication details, date of birth, and symptom updates are private health information. Only the patient and authorized care team members should be able to read the answers.

Tips

• Tell patients how long refill requests usually take to review.
• Add instructions for urgent concerns or worsening symptoms, since this form may not be monitored immediately.
• Ask patients to confirm the pharmacy name and location before submitting.

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