Prescription Request Form

This request form is for Clarity Health Care clients who are currently engaged with a psychiatrist, requesting a repeat prescription for existing medications.

Prescription Request Form

Name(Required)

First Last

Phone(Required)

Email(Required)

Select your psychiatrist(Required)

Note: This request form is for Clarity Health Care clients who are currently engaged with a psychiatrist, requesting a repeat prescription for existing medications.

What is the medication name (brand or generic), dosage and quantity that you need? If you need more than one medication, use the + button to add more rows. Please only include one medication per row.(Required)

Medication name

Dosage

Quantity

Would you like to include a note for your psychiatrist?