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Prescription Refill Request

As a courtesy to our patients, prescription refills may now be requested using our form below. Please note this service is for routine refills, where there are no changes required in medication or dosage. Should you require any changes, please request an appointment.

THIS REFILL REQUEST FORM IS FOR ME IF:

i am a current patient of the clinic

This service is for current patients only who have seen their Provider in 6 months or less.

my previous appointment was > 6 months ago

Please ensure you have met your Provider in the past 6 months or less to ensure your medications are working for you.

i attended my previous appointment

Attendance has its benefits! Only patients who attended their last appointment may use our Refill Request service.

i have a future appointment scheduled

Refill Requests are for patients who are in-between appointments and require their prescriptions.

Continue to Refill Request Form

Request an Appointment

Contact our Office

Prescription Refill Request

Kindly complete this refill request form as accurately as possible. This form is for routine refills only. If you wish to make any changes, kindly email [email protected] to schedule an appointment with your Provider.

Refill Request Policy(Required)

Please select all that apply.

I am a current patient of Alabama Psychiatry & Counseling

My previous appointment with my Provider was less than 6 months ago

I attended my previous appointment with my Provider

I have scheduled a future appointment with my Provider

This refill request requires no changes from my prior prescription.

I understand that my Refill Request will not be processed unless the above conditions are met

What is your current medication status?(Required)

Please select the answer that best describes you.

I currently have more than one week of medication

I currently have less than one week of medication

I am currently out of medication

Other

ABOUT YOU

Patient's Name(Required)

First Last

Parent / Guardian's Name

First Last

Patient's Date of Birth(Required)

MM slash DD slash YYYY

Email(Required)

Enter Email Confirm Email

Phone Number(Required)

Alternate Phone Number

Provider(Required)

Please select one.

Date of Last Appointment(Required)

MM slash DD slash YYYY

Please provide the date of your last appointment with your Provider. If your appointment was over 6 months ago, please Request an Appointment.

Date of Scheduled Appointment(Required)

MM slash DD slash YYYY

Please provide the date of your next scheduled appointment with your Provider. If you do not have an appointment scheduled, please Request an Appointment.

YOUR PRESCRIPTION

Date of Last Prescription

MM slash DD slash YYYY

This is available on your prescription bottle.

Drug(Required)

Dosage(Required)

Frequency(Required)

If Other, please describe.

Drug

Dosage

Frequency

If Other, please describe.

Drug

Dosage

Frequency

If Other, please describe.

Drug

Dosage

Frequency

If Other, please describe.

Please list any other medications for which you require a refill.

YOUR PHARMACY

Has your Pharmacy changed from your previous refill request?(Required)

Same Pharmacy per previous prescription request

New Pharmacy

Pharmacy Name(Required)

Address(Required)

Street Address Address Line 2 City State Zip Code Country

Phone Number(Required)

Fax Number

Email

ACKNOWLEDGEMENTS

By selecting the above checkboxes, I acknowledge these terms and conditions and provide consent to transmission of the form. I understand information submitted may be sent through release Alabama Psychiatry and Counseling and its employees, agents, and subcontractors from all responsibility or liability for any claims or damages arising from the content of the form or the transmission thereof.(Required)

By selecting the above checkboxes, I acknowledge these terms and conditions and provide consent to transmission of the form. I understand information submitted may be sent through release Alabama Psychiatry and Counseling and its employees, agents, and subcontractors from all responsibility or liability for any claims or damages arising from the content of the form or the transmission thereof.

It may take up to 5 business days for my request to be processed.

Requests received after 5:00pm on weekdays, over weekends or holidays will be processed on the next business day.

I will check with my pharmacy before picking up my prescription to ensure that the request has been filled.

If my pharmacy has not received my prescription, if there is an error, or if my request is urgent, I will email [email protected]

Don't meet the criteria for a refill? No sweat.

We are here to help. Please request an appointment with your provider so we can get your refills to you in time.

Request an Appointment

Questions regarding your Refills or need to schedule an appointment?

Your name Please enter your name.

Your email Please enter a valid email.

Your phone Please enter a valid phone number.

Your message Please enter a message.

Message failed. Please try again.

Thank you for your message!

Our Care Team will review shortly and respond via email.

Please note due to the high volume of requests, it may take up to 3 business days for us to respond.

We understand sometimes medications run low and that can be very stressful. Not to worry, please call our office at 205-440-6292 if you require urgent care and we will be happy to assist you.

AlabamaPsychiatry_Final

ADDRESS

2016 Stonegate Trail, Suite 112

Vestavia Hills, Alabama 35242

PHONE

(205) 440-6292

FAX

(205) 313-3177

EMAIL

[email protected]

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