REQUEST PRESCRIPTION REFILL

Prescription Refill Requests

If you are a current client of Lisa Ann Miles and need your prescription(s) reviewed for refill, please first check with your pharmacy to ensure you've exhausted any built-in refills that may have been included last time.

Then, please complete the brief form below to have your refill request reviewed by Lisa Ann Miles. Prescription refill requests may take up to 3 Business Days.

A controlled substance ie sleeping medication, anxiety medication, stimulants require a visit with the NP every 12 weeks if you have not had a visit in 12 weeks the refill will not be completed.

REQUEST PRESCRIPTION REFILL
FORM

At your client visit, you are given enough refills until your next visit.
You may need a follow up visit before your prescriptions are filled.

First Name

Date of Birth

Email Address

Last Name

What is your Preferred Phone #?

Confirm Email Address

Patients Address

Name of your Pharmacy

Pharmacy Address

MEDICATION(s) With DOSAGES You Need Reviewed for Refill

If you are requesting a controlled substance; such as Adderall, Ambien, Klonopin, etc., and it has been more than 12 weeks since your last visit, then you will need a follow up visit before your medication is filled.

I understand that by submitting this online request, my Prescription Refill information will be sent electronically for review. I understand that Prescription Refill Requests take a minimum of 1 Business Day to be processed, and may take up to 3 Business Days if a Prior Authorization or more detailed review is necessary. I understand that if I am experiencing a medical, psychiatric, or mental health emergency, I am expected to call 911, contact a crisis resource, or visit my local Emergency Room.

Thanks for submitting!

CONTACT

SCHEDULE A FOLLOW UP

REQUEST PRESCRIPTION REFILL

Prescription Refill Requests

REQUEST PRESCRIPTION REFILL FORM

At your client visit, you are given enough refills until your next visit. You may need a follow up visit before your prescriptions are filled.

REQUEST PRESCRIPTION REFILL
FORM

At your client visit, you are given enough refills until your next visit.
You may need a follow up visit before your prescriptions are filled.