**PLEASE DO NOT COMPLETE MULTIPLE REFILL REQUESTS FOR THE SAME MEDICATION, THEY WILL BE FILLED WITHIN 3-4 DAYS.**

*Please try to send your request in 3-4 days prior to your last dose, as we are only in clinic on certain days each week.*

No prescriptions will be refilled when the office is closed, on weekends or on holidays.

Refills can only be authorized on medications prescribed by doctors or nurse practitioners in our office to established patients of Khan Psychiatry. We will not refill medications prescribed by other doctors.

OUR OFFICE DOES NOT RECIEVE REFILL REQUESTS FROM PHARMACIES. ALL REQUESTS MUST BE COMPLETED BELOW.

Refill Request

Patient's Legal First Name *

Patients Legal Last Name *

DOB * +

Pharmacy Name & Address *

Pharmacy Telephone Number *

Which provider do you see? Dr Khan or NP Emily? *

Is this your Primary Pharmacy? *

Is this a Pharmacy Change? *

Medication Name *

Dose (mg) *

Frequency *

Medication Name

Dose (mg)

Frequency

Medication Name

Dose (mg)

Frequency

Medication Name

Dose (mg)

Frequency

Medication Name

Dose (mg)

Frequency

Medication Name

Dose (mg)

Frequency

Medication Name

Dose (mg)

Frequency

Medication Name

Dose (mg)

Frequency

Any additional notes (i.e. if your insurance requires a 90 day supply, OR PHARMACY CHANGE, etc)