Prescription Refill Request template

A refill request form that gets the pharmacy phone call out of your queue: patient name, date of birth, callback number, the medication as printed on the label, the prescribing provider, the pharmacy, and — the field that makes triage possible — how much medication the patient has left, from "none" to "more than a week."

Use this template Start free — no card

8 questions · works on the free plan (500 responses/month) · fully customizable

What’s inside

The questions this template ships with — rename, reorder, or delete any of them in the builder.

01Patient's full nameShort text

02Date of birthDate

03Best number to reach youPhone number

04Medication name and dosageShort text

05Prescribing providerShort text

06Pharmacy (name and location)Short text

07How much medication do you have left?Multiple choice

When to use this template

A primary care office replacing a refill voicemail line that staff transcribed into the queue every morning
A practice that wants refill requests triaged by urgency, using the supply-remaining answer to sort the day's list
A clinic whose patients use several pharmacy chains, where "name and location" prevents sending refills to the wrong branch
An after-hours option so patients can file requests at 9 pm instead of calling at 8 am

Tips to get more from it

The supply-remaining question is the triage engine — "None — I've run out" and "1–3 days" requests deserve a same-day look, and the answer exports in its own CSV column for sorting
The medication field's helper text asks for the label wording, e.g. lisinopril 10 mg; that phrasing does real work reducing clarification callbacks, so keep it
Prescriber is deliberately optional — the helper text says staff will look it up — because requiring it stalls patients who only know "my doctor"
The ending quotes a 2-business-day turnaround and warns a visit may be needed first; align both statements with your actual policy before publishing

Questions people ask

Does submitting this form refill the prescription automatically?

No. It sends a request to the practice, where staff and the prescribing provider review it — the ending tells patients the practice will call if a visit is needed before the refill.

How quickly are online refill requests processed?

That's up to the practice. This template's ending states a typical 2-business-day window; edit that text to match your own turnaround before you publish.