Refill requests require 3 business days' notice to process

If the medication is not ready at your pharmacy 3 business days after you submit a refill request, please confirm they have received it (sometimes a pharmacy backlog prevents this) and confirm the medication is in stock.

Patient First Name *

Patient Last Name *

Patient Date of Birth *

Who is Completing This Form (First & Last Name) *

Requestor Relationship *

Requestor Email Address *

Requestor Phone Number *

Medication Name *

Dose (mg/ml) *

Days Supply *

Preferred Pharmacy *

Preferred Pharmacy Address *

Message (ONLY IF NECESSARY) This area is only for refill specific details - this is not for clinical questions or comments.

Required Acknowledgements

	I understand and agree to the refill policy in its entirety. Any deviation from that policy will result in further delays.	I have called the pharmacy and confirmed that the medication is in stock	I agree that a $15 refill processing fee will be billed to my account when the refill is submitted	I will call Raleigh Psychology at 919-346-3204 if the refill has not been received by my pharmacy within 72 hours.
Please check each box to acknowledge that you understand each component

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