Prescription Refill Form

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. 

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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.

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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 Authorize.net. 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.

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.

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