Medication Refill Request Form

Simplify Medication Refills with a Smart Online Form

Managing prescription refills shouldn't be complicated. Whether you're running a busy clinic, pharmacy, or telehealth practice, our Medication Refill Request Form template makes it easy for patients to request their medications online—no phone calls, no waiting on hold, and no manual paperwork.

Built with Paperform, this template helps healthcare providers and pharmacies streamline the refill process while keeping patient information secure and organized. It's perfect for medical practices, independent pharmacies, hospital systems, and telehealth platforms looking to improve patient experience and reduce administrative burden.

Why Healthcare Providers Choose This Template

Save time for your team
Instead of fielding phone calls all day, your staff can process refill requests from a centralized dashboard. Conditional logic guides patients through the right questions based on their medication type and delivery preferences, so you get complete, accurate information every time.

Improve patient satisfaction
Patients can submit refill requests 24/7 from any device—whether they're at home on their laptop or on the go with their phone. The form adapts to their needs, asking about pharmacy preferences, pickup or delivery options, and even insurance details when needed.

Stay compliant and secure
Paperform is SOC 2 Type II compliant and offers robust security features to protect patient information. While not HIPAA compliant, this form can be used for non-PHI medication requests and general healthcare communications. You can collect essential information while maintaining patient privacy and data security standards.

Integrate with your existing systems
Connect this form to your pharmacy management system, patient records, or CRM using Paperform's native integrations or Stepper for advanced workflow automation. Send refill requests directly to your dispensing system, trigger SMS notifications to patients when prescriptions are ready, or update your inventory tracking—all automatically.

Perfect for These Healthcare Settings

• Community pharmacies taking refill requests online and reducing phone volume
• Medical clinics and practices managing prescription renewals for regular patients
• Telehealth providers coordinating medication delivery with remote patients
• Hospital outpatient pharmacies streamlining discharge medication refills
• Specialty pharmacies handling complex medication regimens and patient follow-ups
• Assisted living facilities coordinating resident medication management

How This Form Works

The template guides patients through a simple, conversational flow:

1. Patient verification – Collect name, date of birth, and contact details to confirm identity
2. Medication details – Capture prescription name, dosage, and prescribing physician
3. Pharmacy selection – Let patients choose their preferred pharmacy location or confirm their regular pharmacy
4. Delivery preferences – Offer pickup, delivery, or mail order options based on your services
5. Insurance information – Optionally collect insurance details for billing
6. Special instructions – Allow patients to add notes about timing, allergies, or concerns

Conditional logic ensures that patients only see relevant questions. For example, if they select delivery, the form asks for their address; if they choose pickup, it offers available time slots.

Automate Your Refill Workflow with Stepper

Take your medication refill process to the next level by connecting this form to Stepper, Paperform's AI-native workflow automation platform. When a patient submits a refill request, Stepper can:

• Check prescription eligibility and refill counts in your pharmacy system
• Route requests to the appropriate pharmacist for approval
• Send automated SMS or email confirmations to patients
• Update inventory and flag medications that need ordering
• Create tasks for delivery drivers or notify patients when ready for pickup
• Log everything in your CRM or patient management system

With Stepper, you can build sophisticated, multi-step workflows without writing a single line of code—perfect for busy healthcare operations teams.

Designed for Real Healthcare Workflows

This template was built with input from pharmacists, clinic administrators, and healthcare operations professionals. It balances thoroughness with simplicity, collecting the information you need while keeping the patient experience smooth and respectful of their time.

The form uses a clean, professional design that instills confidence and works beautifully on mobile devices—because most patients will fill it out from their phones while thinking about their medication needs.

Get Started in Minutes

With Paperform, you can customize this template to match your practice's branding, add your logo, adjust the questions to fit your workflow, and start accepting refill requests immediately. No technical skills required—just type and format like you would in a document.

Whether you're a solo practitioner looking to reduce phone interruptions or a large pharmacy chain standardizing your refill process across locations, this template gives you a professional, HIPAA-appropriate foundation that you can launch today and refine as your needs evolve.

Ready to streamline your medication refills? Start with this template and experience how Paperform transforms everyday healthcare operations into smooth, automated workflows that your team and patients will love.