Prescription Refill Request

Please fill out the form below to submit a refill request.

Full Name *

Date of birth *

Phone *

Email *

Prescription Name *

Dosage *

Pharmacy Name *

Pharmacy Crossroads *

Anything you would like your provider to know before submitting your request?

Refill Request Policy & Authorization

By submitting this refill request form, you acknowledge and agree to the following:

Prescription refills require that you remain current with your provider visits. If more than ninety (90) days have passed since your last appointment with Lively Integrated Health, your refill request may be subject to a $50 refill authorization fee. This fee will be charged to the card on file prior to processing the refill.

This refill fee does not apply to patients enrolled in the Lively Wellness Club. Active Wellness Club members will have this fee waived.

Weight loss medications are excluded from this refill fee policy and may be subject to separate guidelines and appointment requirements.

Submission of this form does not guarantee approval of a refill. All refill requests are subject to provider review and clinical discretion. Lively Integrated Health reserves the right to require a follow up appointment prior to authorizing any prescription refill.

By submitting this request, you authorize Lively Integrated Health to charge the applicable refill fee, if required, to the payment method on file.