Medication Refill Request
Austin PsychCare

For prescription refills, first please call your pharmacy and check if you have refills available. If not, have the pharmacy send a refill request. If you are having difficulty getting a hold of your pharmacy for a refill request, please fill out the following form, which will be sent to your provider.
Controlled medications (i.e. Adderal, Xanax) prescribed outside of scheduled appointments will be charged a $35 prescription refill fee.
Please fill out ALL SECTIONS and then hit “Submit Refill Request” button.
Refills will be automatically denied if a section is missing. Thank you!

Name of Provider

Your Name

Date of Birth

YYYY

Best Phone Number to Reach you

Email address

Preferred Pharmacy (Please include address and phone number)

Medications being requested (e.g. Advil). Please include dose (e.g.200 mg) and how you are taking the medication (e.g. twice a day)

Further comments/instructions (optional)

Please check the following box

I understand that this is a refill request. IT DOES NOT MEAN THAT I WILL RECEIVE THE MEDICATION. My provider will carefully review the request and determine whether to approve it, deny it, or request a follow-up appointment,

Medication Refill RequestAustin PsychCare

Thank you for your refill request. We will be reviewing your request shortly.

Medication Refill Request
Austin PsychCare

Thank you for your refill request.
We will be reviewing your request shortly.