Refill Request

Compassionate Counseling Company

Client First Name

Client Last Name

Client Date of Birth

Guardian Name

Phone Number

Email address

Medication Name

Current Dose

(i.e. 10mg, 50mg, etc)

Current Dosage Frequency

(i.e. daily, twice daily)

Last dose taken (date/time)

Are you requesting any changes to this medication?

Yes

NOTE: any changes to your medication dosage may require an appointment with your provider before the refill request can be completed. Please contact 774-322-2340 to schedule an appointment.

Dosage Requesting

Pharmacy Name

Pharmacy Address

Have you missed any doses of this medication recently?

Yes No

Please provide additional details

Have you experienced any new side effects since your last visit?

Yes

Please provide additional details

When was the date of your last appointment with your prescriber?

Do you have a follow up appointment scheduled with your provider?

Yes

What is the date of your next scheduled appointment?

A follow up appointment must be scheduled before any refill requests can be completed. Please contact our office as 774-322-2340 to schedule.

Refills are processed during regular medication management office hours only (Monday–Tuesday, 8:00 AM–5:00 PM).

To ensure timely processing, refill requests must be submitted at least five (5) business days in advance and no later than the Monday prior to when the refill is needed.

We are unable to accommodate early, emergency, or same-day refill requests. Requests submitted outside of these guidelines may not be processed in time.

Refills will not be processed during evenings, weekends, or holidays.

Please do not come to the office requesting a refill unless instructed to do so by our team.

I have read and understand the above listed refill request policy

Submission of this form does not guarantee that your refill will be processed immediately. If your request was submitted with less notice than outlined above, we may not be able to fulfill it the timeframe that you are requesting. If there is additional information required to process this request a member of our team will reach out.

Your information will be encrypted.

Refill Request

Compassionate Counseling Company

Compassionate Counseling Company

Compassionate Counseling Company

Medication Management Services