Refill Requests

PLEASE NOTE: We require patients and families to request a refill FIVE BUSINESS days before running out of medication to ensure that we can process the request and send it to the pharmacy. If you do not receive your refill within 5 business days, please contact the office for further assistance.

We do not accept refill requests from the pharmacy.

Patient Name(Required)

First Last

Date of Birth(Required)

Pharmacy Information

Pharmacy Name(Required)

Pharmacy Phone(Required)

Pharmacy Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Medication Information

Name of Medication 1(Required)

Medication 1 Dose(Required)

Name of Medication 2

Medication 2 Dose

Name of Medication 3

Medication 3 Dose

Name of Medication 4

Medication 4 Dose

Please provide an update on how the patient is doing.(Required)

For controlled medications (stimulants for ADHD or benzodiazepines for anxiety): You can request the medication in advance of the date it is due, however do not pick up the medication from your pharmacy until the 30th day after your last fill.(Required)

I understand

Patients on controlled medications are required to be seen every 3 months. If you are due for an appointment, please call the office at 502-896-2606 or email meds@squareonemd.com(Required)

I understand

To ensure this is processed smoothly, we encourage you to check with your pharmacy to make sure the requested medication is in stock.