An online prescription refill request lets a patient ask their clinic for a refill and gives the clinic the details it needs to decide. The clinic decides whether a refill is approved, not the form, and some medicines, such as controlled substances, may need a call or a visit under your clinic's rules. Write those limits into the form and the confirmation text so patients know when to call instead.
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The patient wants a different dose, strength or medicine. A clinician has to decide that, so the form only passes the request along.
Your clinic lists this medicine as one that needs a call or a visit. Show a notice and the clinic's phone number instead of collecting a refill request.
The clinic sends approved refills to a pharmacy that takes requests by fax or a secure portal rather than by phone.
| Field | Type | Required | Why you ask it |
|---|---|---|---|
Patient name | Short text | Required | Matches the request to the right chart. |
Date of birth | Date | Required | Helps the clinic confirm identity before a clinician reviews the medicine. |
Medicine name and strengthCopy the name and strength exactly as they appear on the label. | Short text | Required | Shows which prescription the clinician should check. A name alone can match more than one strength. |
Pharmacy name | Short text | Required | Shows where an approved refill should go once a clinician has decided. |
Pharmacy phone | Phone | Required | Lets the clinic confirm the pharmacy's details before it sends anything. |
Days of medicine left | Number | Required | Shows how soon the patient needs a decision. A low number is a reason to call the clinic, not to wait for the queue. |
Last fill date | Date | Optional | Shows when the medicine was last filled, so the clinician can see the timing. |
Is this a controlled or visit-only medicine?If you are not sure, choose I am not sure. The clinic will tell you the next step. NoYesI am not sure | Single choice | Required | Answering yes or not sure means the clinic should send the patient to a call or a visit. Your clinical lead defines the list of medicines that qualify. |
Prescribing clinician | Short text | Optional | Names the clinician who wrote the prescription, so the request reaches the right person. |
Phone number for a question | Phone | Required | Lets the clinic reach the patient if the request needs a conversation before a decision. |
Notes about the requestDo not describe symptoms, side effects or changes in how you feel here. Call the clinic about those. | Long text | Optional | Gives the clinician context about the request itself, such as a pharmacy closure. |
Limits of this formI understand the clinic decides whether to approve a refill, and that this form is not for urgent needs | Multiple choice | Required | Makes the limits explicit before the request is sent, so nobody reads them as a promise. Your clinical lead should approve the wording. |
Estimate based on question types; actual completion time varies.
A refill form is a queue, not a triage process. Send symptoms, side effects and urgent questions to a phone line or visit your clinic staffs, and say so on the form.
If the clinic reviews requests in batches, say so and say when the batch runs. A vague promise that a refill will be ready by a certain time leaves the patient waiting on a time that may not hold.
Ticking a box does not make a medicine eligible. Route any yes or not-sure answer to a clinician before anyone treats the request as approved.
Without a pharmacy name and phone number, the clinic has to go back to the patient before it can act on an approved refill. Keep both fields required.
Once a clinician decides, record the decision in your clinical system. The form's grid shows the request, not the outcome.
Decide who reads new refill requests, when they read them, and the time of day after which a request waits until the next working day. Put that schedule in the confirmation text.
The form only collects the request. A clinician, or a process your clinic has approved, decides whether to refill it, and the form never approves a refill on its own.
The hourly production run handles each request, and the creator hears about it afterwards. A patient who is about to run out should call the clinic rather than wait for that run.
Exports are CSV files. Refill exports show medicine names and pharmacy details, so decide who may export them and when old files are deleted.
They can, through a form like this one, if your clinic accepts refill requests that way. The form collects the request. The clinic decides whether to approve it and how an approved refill reaches the pharmacy.
The medicine name and strength as shown on the label, the pharmacy name and phone number, the patient's name and date of birth, and how many days of medicine are left. Leave out symptoms and a full medication list, which belong in a conversation with the clinic.
A template helps you list fields, but the rules must be your clinic's: which medicines are eligible, how much notice you need and who answers. Have your clinical lead check the wording before you publish the form.
Set that number yourself and publish it. Tell patients how many business days your clinic needs, and ask them to call if they have fewer days of medicine left than that.
Choose a category and a form type in the wizard. Answer three Atty Suggestions questions, then give the form a title. Atty builds the fields in the background. Edit the fields and ask Atty to refine them, then publish and share the /f/ link.
