Use our free prescription refill request form template to allow your patients to easily request refills digitally! Patients no longer need to call the office or wait on hold when they need a simple medication refill. They can easily access this form on their own and use it to order multiple prescriptions at once using our repeating sections feature. The template includes fields to collect the patient’s information as well as various details about the medications they are looking to refill.

Additionally, there’s an internal section that your clinic manager or staff member can use to log and track updates regarding the refill’s approval status and if it’s been documented in the EMR. The clinic manager will be notified of a new refill request and provided a link to access the entry via email using our workflow link sharing feature. Using the Entries page and workflow statuses, your clinic manager can efficiently monitor and view what stage the refill is in throughout the process.

All data collected can be made HIPAA compliant with our Enterprise plans after signing our Business Associates Agreement (BAA). Additionally, our data encryption capabilities can help ensure your data is secure both at rest and in transit.

Feel free to customize this template by adding, removing, and editing fields as you see fit. You can brand it with your logo and style it as you please using our Organization Theme feature.