Please complete the secure form below to request a prescription refill. This form is encrypted, HIPAA-compliant, and powered by Hushmail to protect your personal health information. A pharmacist will review your request and contact you if any clarification is needed.

Alternative Request

Please submit form or call during business hours

(214) 484-1393
(844) 703-1780

Patient Full Name

Date of Birth

Phone Number

Email address

Medication Name

Dosage/Strength

Rx Number (if known)

Last Fill Date (if known)

# of Refills Requested

Notes or Special Instructions

Doctor/Provider Name

Clinic or Practice Name

Provider Phone / Fax

Delivery Address (if selected)

By submitting this form, I confirm that I am the patient named above or their legally authorized representative. I authorize Shepherd Specialty Pharmacy to review and process my prescription refill request using the information provided. I understand that a valid prescription must be on file and that refills for certain medications may require prescriber approval. I acknowledge that I have reviewed the information for accuracy and consent to communication by phone, text, or email if clarification is needed.

I have read and agree to the Authorization & Agreement above.

Typed Signature

Your information will be encrypted.