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Prescription Refill Request

Take refill requests off the phone. Patients give the medication, the dose, and the pharmacy in one pass, and nothing gets misheard.

Prescription Refill Request

Take refill requests off the phone. Patients give the medication, the dose, and the pharmacy in one pass, and nothing gets misheard.

The medication

Where to send it

Pharmacy address

Pharmacy address

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Use this template

Opens in the builder. Nothing is saved until you edit it.

Fields
11 questions
Theme
Default, switchable in the preview
Updated
11 August 2026

Categories

  • Healthcare
  • Healthcare Forms
  • Request Forms
  • Patient Forms

Ideal for

  • GP surgeries
  • Clinics
  • Pharmacies
  • Practice managers

Best used in

  • Repeat prescriptions
  • Patient portals
  • Out of hours requests

About this template

Refill requests taken by phone are the easiest thing in a practice to get wrong, because drug names sound alike and doses are read out from memory. In writing, the patient copies what is on the box, and the request that reaches the prescriber is the request the patient meant to make.

How much supply is left is the field that lets you triage the queue. Somebody with two weeks of medication can wait for the routine run, and somebody who has run out today cannot, and knowing the difference before you open the request is what stops both from being treated the same.

The question about what has changed catches the case that matters clinically: a refill request is often the first sign that something else is going on. Add the pharmacy as a dropdown if you work with a fixed list, and make the urgency field required if you publish a turnaround time.

Templates are a starting point, not legal or professional advice. Where a form carries consent, medical, or contractual wording, have somebody qualified review it against the rules that apply to you before you publish.

Fields in this template

  • Full name*Short text
  • Date of birth*Date
  • Best number to reach you*Phone
  • Email addressEmail
  • Which medication do you need?*Long text
  • How much do you have left?*Dropdown
  • Has anything changed since your last prescription?*Single choice
  • If yes, what changed?Long text
  • Pharmacy name*Short text
  • Pharmacy addressAddress
  • How soon do you need it?Single choice

Every field can be renamed, reordered, made optional, or removed once the template is open in the builder.

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