Request Prescription Refill | Life Management for

REQUEST MEDICATION REFILL

First Name

Last Name

Phone

Date of Birth

DUE TO SHORTAGES OF ADDERALL please contact your pharmacy to confirm they have your current dose in stock.

If your pharmacy does not have your prescribed dose you can ask:

- Can they check other locations availability

- Are there alternate forms available (example: instead of 20 mg tablets do they have 10 mg tablets)

- You can call to check other pharmacies for availability

1) Medication Name, Dose and Instruction

2) Medication Name, Dose and Instruction

3) Medication Name, Dose and Instruction

Pharmacy Name and City

Day Supply

If a Prior Authorization is required to refill your prescription you need to be sure we have your current Insurance and Prescription benefit information.

To expedite the process you can attach a picture of your insurance card to this refill request.

Upload Insurance Card

FRONT of card

BACK of card

You have successfully submitted your refill request!- Please allow 24 to 72 Business Hours for Prescription Refills -Once your provider has sent your prescription to the pharmacy you will receive a text message from our office.