Independent Pharmacy Automatic Refill Enrollment Form

Managing multiple prescriptions can be overwhelming, especially when refills fall on different days throughout the month. Our Independent Pharmacy Automatic Refill Enrollment Form makes medication management simple by synchronizing all your prescriptions to a single monthly pickup or delivery date.

Built with Paperform, this template helps independent pharmacies modernize their patient experience while reducing missed doses and improving medication adherence. The form captures essential patient information, current medications, synchronization preferences, and delivery schedules—all in one streamlined workflow.

Perfect for independent pharmacies looking to compete with large chains by offering personalized, tech-enabled services. The auto-refill program reduces phone calls, improves inventory management, and strengthens patient relationships through convenient, reliable service.

With Paperform's conditional logic, the form adapts based on patient preferences—showing delivery address fields only when delivery is selected, and customizing communication preferences for each patient. Integration capabilities mean submissions can flow directly into your pharmacy management system, trigger reminder emails through your CRM, or connect with Stepper (stepper.io) to automate the entire enrollment workflow—from verification to insurance checks to confirmation calls.

For pharmacies serving elderly patients or those with chronic conditions, this template transforms medication management from a monthly hassle into a set-it-and-forget-it service that improves health outcomes and patient satisfaction. The form is mobile-friendly, WCAG accessible, and designed to work seamlessly on any device, making enrollment easy for patients of all technical skill levels.