Simplify your workflows

Many patients prefer to refill prescriptions online. With this mobile-friendly form, you can make refills easier for customers and pharmacists alike. Just customize the template with your company logo to get started. You can use the form as-is or tweak the fields to match your exact prescription refill process. Either way, you’ll be ready to accept online requests within minutes. Embed it on your website, enable secure online payments, send confirmation emails, and more—all with the same digital form.

Save time and refill faster

Eliminate the need for phone calls by embedding this mobile-friendly prescription refill form on your website. Simply add your company name or logo and customize fields as needed. Then share the form with patients and consumers so they can request refills digitally. 

Streamline your refill process

Formstacks’ prescription refill form template comes packed with features to make your job easier. Use Confirmations and Notifications to ensure patient and medication details reach the right pharmacist fast, and to let patients know when, where, and how they’ll receive orders. Forms API and Webhooks also let you sync the data to existing technology solutions.

Collect payments online

Make it even easier for patients to refill prescriptions by allowing them to pay online. You can redirect users to payment processors like PayPal and Or add PCI compliant credit card fields directly to your form to securely collect payment data. Either way, you can offer the convenience of online payments without worry.

Keep prescription data secure

When used with Formstack’s HIPAA plan, you can rest assured any patient information you collect with your form will remain compliant. Additional Form Security features like 256-bit SSL, data encryption, and PGP email encryption ensure the prescription refill information you collect and circulate will be protected against cybercriminals and breach attempts.

Formstack's intuitive interface helps us build and modify a variety of medical forms to collect new patient data and route patient communication forms to medical assistants, the front office, billing, and administration.
Dr. Chris Bojrab
President of Indiana Health Group

Ready to get started with this template?

Click the button below to add this template to your account. If you do not have an account, you can sign up for a free trial to start using this template.
Get This Template