IP - Refill Request - InnovativePsychiatry

Request a Refill

* Indicates required field

Name *

First

Last

Please be sure to check with your pharmacy to ensure that you do not have existing refills before completing this form.

Due to strict regulations, we are unable to provide early refills for controlled substances. *

By checking this box, I confirm that I have less than 5 days of medication / 3 days left of a controlled substance

Email *

Medication and Dosage *

How would you like to receive the prescription? *

Pharmacy *

Date of Birth *

Comments *

Patients are required to be seen every 90 days in order to receive refills per our office policies.
If you have not been seen within 90 days, please call the office at 443-542-0773.

Effective August 1, 2021 - All patients that are being prescribed a controlled substance must come in person for follow up appointments.

Please note - refills will be sent within 48 hours of your confirmation email. Please do not contact the office unless you do not receive a confirmation email or the 48 hours have passed.

Submit

If you are requesting that a medication be sent to an out of state pharmacy, please download and complete this form and email to admin@ecpsychiatry.com
(with the exception of Northern Virginia)

Request a Refill

If you are requesting that a medication be sent to an out of state pharmacy, please download and complete this form and email to admin@ecpsychiatry.com (with the exception of Northern Virginia)

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If you are requesting that a medication be sent to an out of state pharmacy, please download and complete this form and email to admin@ecpsychiatry.com
(with the exception of Northern Virginia)