Medication Refill Request form

Patient Name

Phone

Home Address

Provider Name

Medication name and dose refill request

Pharmacy Name

Pharmacy Name and address

"NO-SHOWS": A 'no-show' is someone who misses an appointment without canceling it in the proper manner. A failure to be present at the time of the scheduled appointment will be recorded in your medical record as a 'no-show'. If you are a 'no-show' for your first appointment with a physician, physician assistant, or nurse practitioner, you will be charged $200. If you are a 'no-show' for your first appointment with a therapist, you will be charged $100. A credit card or debit card is required prior to your first appointment. For each 'no-show' follow-up appointment, you will be charged $50. All 'no-show' fees must be paid prior to your next appointment. If you have three (3) or more 'no-shows', you may be discharged from the practice. There is a $10 fees for medication refill.

American Psychiatric Care

"Be happy and content with what you do and make positive changes in self and others"

Child, Adult & Geriatric Psychiatric Services

TMS Brain Stimulation Center

Medication Refill Request form

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