---
title: Tardive Dyskinesia Medication Refill Request Form Template | Paperform
description: Professional TD medication refill form with involuntary movement assessment, antipsychotic history tracking, and specialist review coordination. Built for neurology and psychiatry practices.
url: "https://paperform.co/templates/tardive-dyskinesia-medication-refill-request"
type: static
generatedAt: "2026-03-28T00:45:20.847Z"
---

[← Back to free form templates](/templates/)    ![Tardive Dyskinesia Medication Refill Request](https://img.paperform.co/fetch/f_webp/https://d3gw2uv1ch7vdq.cloudfront.net/content/form_templates/assets/tardive-dyskinesia-medication-refill-request.png)
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### Streamline Tardive Dyskinesia Medication Refills with Paperform

Managing tardive dyskinesia (TD) requires careful monitoring of involuntary movements, detailed medication histories, and ongoing specialist oversight. This **Tardive Dyskinesia Medication Refill Request** template helps neurologists, psychiatrists, movement disorder specialists, and healthcare clinics create a professional, HIPAA-aligned workflow for patients requesting refills of TD medications like valbenazine (Ingrezza) or deutetrabenazine (Austedo).

#### Why healthcare providers choose this template

Tardive dyskinesia medication management goes beyond simple prescription renewals. Providers need to track movement severity, monitor antipsychotic exposure, assess quality of life impacts, and ensure specialist review before authorizing refills. This template collects all necessary clinical information in one structured form:

 - **Involuntary movement scale assessment** using Abnormal Involuntary Movement Scale (AIMS) criteria
 - **Comprehensive antipsychotic medication history** including current and past exposures
 - **Movement disorder symptom tracking** with body region-specific questions
 - **Quality of life impact assessment** to guide treatment decisions
 - **Specialist review coordination** for complex or worsening cases

Built with conditional logic, the form adapts based on patient responses—showing additional questions when movement symptoms worsen, when patients report new antipsychotics, or when specialist consultation is needed. This creates a personalized assessment experience while ensuring clinicians receive complete documentation.

#### Perfect for neurology and psychiatry practices

This template is ideal for:

 - **Movement disorder specialists** managing TD patients on VMAT2 inhibitors
 - **Psychiatrists** balancing antipsychotic therapy with TD risk management
 - **Neurology clinics** tracking involuntary movement progression over time
 - **Mental health centers** coordinating care between psychiatry and neurology
 - **Telehealth providers** conducting remote TD assessments and refill authorizations

#### Automate your medication refill workflow with Stepper

Once a patient submits their refill request, [Stepper](https://stepper.io) can automatically route the submission based on clinical criteria. For example:

 - **Stable patients** with unchanged AIMS scores can trigger an automatic refill approval notification to pharmacy
 - **Patients reporting worsening movements** can be flagged for urgent specialist review and scheduled for in-person assessment
 - **New antipsychotic exposures** can trigger alerts to the prescribing psychiatrist and movement disorder team
 - **Insurance prior authorization requirements** can be automatically initiated based on medication selection

Stepper connects Paperform with your EHR, pharmacy systems, scheduling tools, and communication platforms—turning each refill request into an intelligent, automated workflow that saves clinical staff hours each week.

#### Digital signatures for treatment consent

For patients starting new TD medications or adjusting dosages, you may need documented informed consent. [Papersign](https://papersign.com) lets you automatically generate consent documents from form submissions and collect legally binding eSignatures—all tracked with a complete audit trail. This is particularly valuable for medications requiring Risk Evaluation and Mitigation Strategies (REMS) programs or prior authorization documentation.

#### Designed for healthcare compliance and efficiency

This template includes:

 - **Conditional logic** that reveals relevant sections based on symptom severity and medication changes
 - **Required fields** for critical clinical information needed for safe prescribing decisions
 - **Structured data collection** that can integrate with your EHR or practice management system
 - **Professional medical design** that builds patient confidence and improves completion rates
 - **Mobile-responsive layout** so patients can submit requests from any device

Paperform is trusted by healthcare providers worldwide for forms that balance clinical rigor with patient-friendly design. While Paperform itself is not HIPAA compliant, it offers SOC 2 Type II compliance and enterprise-grade security, with integrations that can connect to your HIPAA-compliant systems for secure data handling.

#### Get started in minutes

Simply customize this template with your clinic's branding, add your specific medication protocols, adjust the movement scale questions to match your assessment preferences, and publish. You can embed the form on your patient portal, share it via secure email, or send it through your EHR's patient communication system.

For neurology and psychiatry practices managing tardive dyskinesia patients, this template transforms a complex clinical assessment into a streamlined digital workflow—giving you more time for patient care and less time on administrative coordination.
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