Medication Refill Requests

Medication Refill Requests

This form is for any current clients who are requesting a refill of their current medications. To ensure the timely filing of your requests, we do ask that you provide us with your refill request 5 days prior to the end of your current script.

Please remember that our Nurse Practitioner's are not readily available everyday, and that there will be a delay in refills of scripts that are sent in with less than 5 days notice.

Please also note that it is at your provider's discretion to refill medication scripts and at certain times they may require that you are seen before refilling scripts. We are prevented from re-filling any controlled substances for clients who have not been seen in 90 days. If you have not been seen in 90 days or more by the Nurse Practitioner call us at (217) 398-9066 to schedule an appointment.

Provider Name*

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Today's Date (Date Submitted)*

Client Name*

Client Date of Birth*

Client Phone Number*

Client Email*

Medication Name(s)*

Please make sure to put the name of the medication as listed on the bottle provided by the pharmacy.

Medication Dosage(s)*

Please list the dosage of the medication (i.e. 40 mg) as listed on the bottle provided by the pharamcy.

Preferred Pharmacy*

Please list the name and address of your preferred pharmacy with as much detail as is available to prevent any confusion in regards to the location. If the pharmacy is different from the current pharmacy that you are utilizing, we are happy to adjust to a new pharmacy per your request.

Reason for Request*

Please provide any details regarding the reason for the request through the drop down menu below. If the reason is not listed choose "other" and provide the details for the reason in "other pharmacy issue".

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Other Pharmacy Issue/Additional Details

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