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Get and Sign Prescription Refill Request Form Template 2012-2022

Get and Sign Prescription Refill Request Form Template 2012-2022

Use a rx refill request pdf 2012 template to make your document workflow more streamlined.

XR or ER for the extended release medications* Dosage:_________________Directions:__________________________ 30day supply 90day (3- 30day scripts) for pharmacy Mail 90day for mail order Pick Up Please note that ADD/ADHD medications CAN NOT be called or faxed into the pharmacy per Texas Laws. They must be picked up or mailed. ****Please note that refills can take up to 48 hours to process so please plan accordingly. There is also a $10.00 charge for all ADD/ADHD medication refills obtained...
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