Teledentistry Prescription Refill Request Form

Please complete this form in full to request a prescription refill. Your responses help us ensure safe and appropriate medication management.

1. Patient Information

2. Prescription Information

3. Symptom & Oral Health Screening

Are you currently experiencing any of the following? (Check all that apply)

4. Medication Use & Compliance

Side effects experienced (check all that apply)

5. Follow‑Up & Care Plan

6. Authorization & Signature

• The practice will review my request and may contact me for further assessment.
• Approval of a refill request is at the discretion of the prescribing provider.
• If clinical evaluation is required, I may be asked to schedule a virtual or in‑office visit.

If signed by guardian/representative

Thank you for your request. We aim to process refill requests within 2 business days.