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Prescription Refill Request Form

Patient Name 
Date of Birth 
Phone Number 


Date of Last Office Visit 
NOTE: If it has been more than 18 months since your last appointment, you will need to schedule a new office visit.


Medication(s) Requested 

(Please refer to your prescription bottle for the following information)

Medication Name #1 
List Dose (in milligrams)
List Frequency if NOT in menu
If OTHER, please indicate time
If OTHER, please indicate number/supply

More medication refills? Please continue. Otherwise, Skip to Last Step ->


Medication Name #2 
List Dose (in milligrams)
List Frequency if NOT in menu
If OTHER, please indicate time
If OTHER, please indicate number/supply

More medication refills? Please continue. Otherwise, Skip to Last Step ->


Medication Name #3 
List Dose (in milligrams)
List Frequency if NOT in menu
If OTHER, please indicate time
If OTHER, please indicate number/supply

More medication refills? Please continue. Otherwise, Skip to Last Step ->


Medication Name #4 
List Dose (in milligrams)
List Frequency if NOT in menu
If OTHER, please indicate time
If OTHER, please indicate number/supply

More medication refills? Please continue. Otherwise, Skip to Last Step ->


Medication Name #5 
List Dose (in milligrams)
List Frequency if NOT in menu
If OTHER, please indicate time
If OTHER, please indicate number/supply

More medication refills? Please continue. Otherwise, Skip to Last Step ->


Medication Name #6 
List Dose (in milligrams)
List Frequency if NOT in menu
If OTHER, please indicate time
If OTHER, please indicate number/supply

More medication refills? Please continue. Otherwise, Skip to Last Step ->


Medication Name #7 
List Dose (in milligrams)
List Frequency if NOT in menu
If OTHER, please indicate time
If OTHER, please indicate number/supply

More medication refills? Please continue. Otherwise, Skip to Last Step ->


Medication Name #8 
List Dose (in milligrams)
List Frequency if NOT in menu
If OTHER, please indicate time
If OTHER, please indicate number/supply

More medication refills? Please continue. Otherwise, Skip to Last Step ->


Medication Name #9 
List Dose (in milligrams)
List Frequency if NOT in menu
If OTHER, please indicate time
If OTHER, please indicate number/supply

More medication refills? Please continue. Otherwise, Skip to Last Step ->


Medication Name #10 
List Dose (in milligrams)
List Frequency if NOT in menu
If OTHER, please indicate time
If OTHER, please indicate number/supply


LAST STEP: How do you wish to recieve the prescription?

Call prescription into pharmacy
Pharmacy Name Pharmacy Phone #

Pick-up prescription at CVAL


Date to Pick-up NOTE: there will be a 48-hour period to complete request.

If your prescription is not ready after 48 hours, or you have any difficulties or questions regarding your prescription refill, please call and leave a message and nurse will call back within 24 hours.

Chesapeake: 757-547-9294, Virginia Beach: 757-419-3000, Princess Anne: 757-419-3000

Mail prescription
Name
Address
City State Zip

Fax prescription
Fax# RX Plan ID#