Please submit this form after you have filled out all of the required fields.  You may save the form and return later to complete it, if you cannot do so in one sitting.

Depending upon your current treatment plan and clinical picture, I may send additional forms to complete before I feel comfortable submitting a refill for your medication(s).

Please note this form is not monitored in real time. If you are currently having thoughts of harming yourself or ending your life, please call 911, go to your nearest emergency room, or contact the 988 Suicide & Crisis Lifeline (call or text 988). You can also text HOME to 741741 to reach the Crisis Text Line. Do not wait for a response to this form.