We understand that
there may be times
when patients will need
refills of medications
but we reserve the
right to deny refill
requests.
Please fill in patient information below
Patient's Provider:
First Name: *
Last Name: *
Patient's Date of Birth: *
MM/DD/YYYY
Primary Contact Number: *
XXX-XXX-XXXX
Email Address: *
Name if different than patients:
Pharmacy Name: *
Pharmacy phone: *
XXX-XXX-XXXX
Reason:
Medication Requested:
Med 1
Dosage
Med 2
Dosage
Med 3
Dosage
Please leave any additional comments below
MEDICATION REQUEST
RULES ABOUT REFILLS

1. All refill requests must be submitted
through this form or by calling (832)
384-1560 option 4 and leaving a voice
mail. We do not accept refill requests over
the phone.

2. Refills after 3:00 pm will be reviewed
the next business day.

3. You must have a future appointment
before we can process your request for a
refill. Before sending in a request, check
with the office to make sure you have an
upcoming appointment. Not having an
appointment will delay or hinder your
ability to get your medication, as we will
deny refills if you are not booked for an
upcoming appointment.  If it is extremely
urgent and you have exceeded your time
between visits, your physician may
prescribe a 7 day supply, at his or her
discretion.

4. Refills may take up to a 3 days to
process. (assuming you are requesting
the refill by this form or by leaving a voice
mail and you have an upcoming
appointment).

5. We ask that you please do not go
through your pharmacy to request
medications. Our office does not accept
faxed request from the pharmacy and
doing so will cause delays in getting your
medication.


We suggest keeping a 7 day supply
of your medication in a separate
bottle to avoid last-minute requests.
Houston Adult Psychiatry