Prescription Refill Request Form
A prescription refill request form has to be exact. Drug name, dose and quantity, because a request that says "my blood pressure tablets" cannot be actioned without a phone call.
For clinics, practices and healthcare providers.
Name, dose, quantity - or it's a phone call
Repeat prescription requests are the highest-volume, lowest-value administrative task in most practices, and the reason they take so long is ambiguity. Two similar drug names, or a dose that changed at the last review, and it goes back to the clinician.
So this template asks for each medication with its dose and quantity as separate prompts, and asks when the patient last had a review. That second question is the one that catches the patient who is three months overdue - which is the whole point of the review system.
Get the details while they're fresh
Reports made verbally get shorter with every retelling, and the detail that mattered is the first thing lost. A form asked at the time captures what happened, when, and who was there - in the words of the person who saw it.
Paperwork before the appointment, in the patient's own time
Forms filled in at reception are rushed, incomplete and hand-written. The same questions sent with the appointment reminder come back typed, complete and read at home - and you get the first ten minutes of the appointment back.
They also arrive before you need them, so a flagged medication or a mobility need changes the plan in advance rather than in the room.
Ask what has to be asked
Required fields for the facts that make a report usable, optional ones for everything else - so you're never left with a report that can't be acted on.
One minute to make it your own
Every label, option and placeholder on this template is editable, and you can add whatever this template doesn't ask. Save to publish, share the link, and export the responses whenever you need them in a spreadsheet.
What this template asks
- Full name
- Date of birth
- Address
- Phone number
- Medication 1 - name, strength and quantity
- Medication 2
- Medication 3
- Anything else
- Has anything changed since your last prescription?
- Please tell us more
- When did you last have a medication review?
- How much do you have left?
- How would you like to collect it?
- Which pharmacy?
- Anything else?
More Healthcare forms
Questions
Should refills be requested this way?
Only for routine repeats, and say so. Anything where the dose has changed, or where the patient is unwell, needs a clinical conversation rather than a form.
Can we send it straight to the pharmacy?
Not automatically - the form collects the request and your usual prescribing process issues it. Asking which pharmacy up front does remove one step.
Can reports be submitted anonymously?
Yes, if you make the name optional. Nothing about the submitter is recorded otherwise - no IP address, no account, no tracking.
Can this go to more than one person?
Yes. Notification recipients are a list, so a report can reach a manager and a safety lead at the same time.
Can I export everything for an audit?
Yes - one click gives you a CSV of every response with its timestamp, which is usually exactly what an auditor or insurer asks for.
Can I use this for patient information?
Responses are stored in your account, never shared and never used for advertising, and pages are served over encrypted connections. You remain the controller of that data: ask only what you need, say what you keep, and confirm your obligations (HIPAA, UK GDPR or local equivalent) before collecting health information on a web form.
Publish your prescription refill request form today
Start from this template and change anything you like. Free to begin.