Medication Refill Request

To submit a request for a medication refill, please fill out all areas of the form below.
Please note that refill requests may take up to 3 business days to be completed.
If you are prescribed a stimulant, it will be sent to your preferred pharmacy within one (1) business day. Due to the national shortage, if we need to resubmit your prescription to a different pharmacy, this can take up to three (3) business days to complete. We are not able to send stimulant refills after office hours during the week or on the weekend.
If you need further assistance or have any questions regarding your medication refill request, please reach out to us by calling (817) 592-2500.

Patient's Name(Required)

First Last

Patient Date of Birth(Required)

Patient Phone Number(Required)

Prescribing Practitioner's Name(Required)

Preferred Pharmacy(Required)

Pharmacy Phone(Required)

Medication Name(Required)

Medication Dosage(Required)

Additional Medication Name

Additional Medication Dosage

Additional Medication Name

Additional Medication Dosage

Additional Medication Name

Additional Medication Dosage

Additional Medication Name

Additional Medication Dosage

Additional Comments

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Email Address

Phone Number

Mon-Fri (8AM - 8PM)

Medication Refill Request

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