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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)
Select Frequency Once a day Twice a day Three times a day Four times a day List Frequency if NOT in menu
When should medication be taken? Morning Afternoon Evening Other If OTHER, please indicate time
# of Tablets to be Dispensed 30 day supply 90 day supply Other If OTHER, please indicate number/supply

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

Medication Name #2 
List Dose (in milligrams)
Select Frequency Once a day Twice a day Three times a day Four times a day List Frequency if NOT in menu
When should medication be taken? Morning Afternoon Evening Other If OTHER, please indicate time
# of Tablets to be Dispensed 30 day supply 90 day supply Other If OTHER, please indicate number/supply

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

Medication Name #3 
List Dose (in milligrams)
Select Frequency Once a day Twice a day Three times a day Four times a day List Frequency if NOT in menu
When should medication be taken? Morning Afternoon Evening Other If OTHER, please indicate time
# of Tablets to be Dispensed 30 day supply 90 day supply Other If OTHER, please indicate number/supply

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

Medication Name #4 
List Dose (in milligrams)
Select Frequency Once a day Twice a day Three times a day Four times a day List Frequency if NOT in menu
When should medication be taken? Morning Afternoon Evening Other If OTHER, please indicate time
# of Tablets to be Dispensed 30 day supply 90 day supply Other If OTHER, please indicate number/supply

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

Medication Name #5 
List Dose (in milligrams)
Select Frequency Once a day Twice a day Three times a day Four times a day List Frequency if NOT in menu
When should medication be taken? Morning Afternoon Evening Other If OTHER, please indicate time
# of Tablets to be Dispensed 30 day supply 90 day supply Other If OTHER, please indicate number/supply

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

Medication Name #6 
List Dose (in milligrams)
Select Frequency Once a day Twice a day Three times a day Four times a day List Frequency if NOT in menu
When should medication be taken? Morning Afternoon Evening Other If OTHER, please indicate time
# of Tablets to be Dispensed 30 day supply 90 day supply Other If OTHER, please indicate number/supply

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

Medication Name #7 
List Dose (in milligrams)
Select Frequency Once a day Twice a day Three times a day Four times a day List Frequency if NOT in menu
When should medication be taken? Morning Afternoon Evening Other If OTHER, please indicate time
# of Tablets to be Dispensed 30 day supply 90 day supply Other If OTHER, please indicate number/supply

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

Medication Name #8 
List Dose (in milligrams)
Select Frequency Once a day Twice a day Three times a day Four times a day List Frequency if NOT in menu
When should medication be taken? Morning Afternoon Evening Other If OTHER, please indicate time
# of Tablets to be Dispensed 30 day supply 90 day supply Other If OTHER, please indicate number/supply

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

Medication Name #9 
List Dose (in milligrams)
Select Frequency Once a day Twice a day Three times a day Four times a day List Frequency if NOT in menu
When should medication be taken? Morning Afternoon Evening Other If OTHER, please indicate time
# of Tablets to be Dispensed 30 day supply 90 day supply Other If OTHER, please indicate number/supply

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

Medication Name #10 
List Dose (in milligrams)
Select Frequency Once a day Twice a day Three times a day Four times a day List Frequency if NOT in menu
When should medication be taken? Morning Afternoon Evening Other If OTHER, please indicate time
# of Tablets to be Dispensed 30 day supply 90 day supply Other 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
Select an Office Chesapeake Virginia Beach

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 messsage and nurse will call back within 24 hours.

Chesapeake: 757-547-9294, Virginia Beach-757-395-5300

Mail prescription
Name
Address
City State Zip

Fax prescription
Fax# RX Plan ID#