This prescription refill request form is for the convenience of our current patients only.

Per our Medication Refill Policy, medication refills are typically provided during regularly scheduled follow-up appointments. This form is intended for urgent refill requests only.

Appropriate reasons to submit this request may include:
• You will run out of medication shortly before a scheduled office visit.
• You’re unable to attend a scheduled appointment due to an emergency.

We may not be able to authorize a refill request if:
• You do not have a follow-up appointment currently scheduled.
• You have not been seen by a provider within the last 90 days, especially if prescribed a controlled substance.
• You frequently cancel or miss appointments with our office.
• You have an outstanding balance for services rendered.

If you need to schedule an appointment, please call (801) 683-9340

Before submitting this request:
• Please contact your pharmacy first to check if any refills remain on your last prescription. Sometimes refills are still available and waiting to be picked up.
• Allow up to 3 business days for a response.
• Please do not call the office to check the status of your request. If you have not received a response after 3 business days, contact us at (801) 683-9340 .

Ready to submit your request?

Please complete the form below in full to avoid any delays.