---
title: Medication Refill Request
date: 2023-04-04T00:12:10Z
modified: 2026-08-10T18:07:49Z
permalink: "https://www.grwhealth.com/current-mental-health-clients/medication-refill-request/"
type: page
status: publish
excerpt: Request routine medication refills online. Fast, secure processing to keep your care on track.
wpid: 1511
timestamp: 2026-08-10T18:07:49Z
tags: []
---

## Medication Refill Request Form

### This MEDICATION REFILL REQUEST FORM is for the convenience of our current patients only.

**Please Read Before Submitting Your Request:**

- Please contact your pharmacy to make sure that you do not have any refills remaining on the last prescription(s) provided by our office.
- Generally, it is our office’s policy that medication refills will only be provided at regularly scheduled psychiatric follow up visits.
- This form is intended for _urgent medication refill requests only_ such as situations in which a patient will run out of medication shortly before a scheduled office visit or situations in which an emergency prevents a patient from attending a scheduled office visit.
- Our administrative office is available to respond to medication refill requests during regular office hours, Monday through Friday from 8:45 a.m. to 5:00 p.m. The length of time needed to respond to your request will depend upon factors such as the office hours of your psychiatric provider and the day of the week you submit your request (we do not respond to requests on weekends or holidays) 
    - We will respond to your request as quickly as possible, but please be aware that it may take up to 2 to 3 business days before you receive a reply.

**Directions:**

Please fill in the form below clearly and completely and include all requested information. Omitting required information will cause a delay in our office responding to your request. **Please DO NOT call the office to check the status** **of your request.** We will respond to your request as quickly as possible, and you will receive a reply from our office.

## Medication Refills

### Patient Info

Name(Required) 
 First
 
 Last

Patient Email(Required)
 
 Date of Birth(Required)
 
 MM slash DD slash YYYY
 Patient Main Phone Number(Required)Date of Next Appointment(Required)
 
 MM slash DD slash YYYY

### Pharmacy Info

Pharmacy Name(Required)Pharmacy Phone Number(Required)

### Medications Needed

Name of Your Psychiatric Provider(Required)Medication Name(Required)Dosage taken per day(Required)Second Medication Name (if applicable)Second Medication Dosage taken per dayThird Medication Name (if applicable)Third Medication Dosage taken per day

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