Patient Prescription Refill Request

WE REQUEST THAT THIS FORM BE COMPLETED IN ORDER TO REFILL YOUR PRESCRIPTION(S).

Please complete this request form to provide Juniper Medical with details of the current prescription(s) for which you are requesting a refill.

You may request refills for up to five (5) medications per request.

Please have your current prescription printout(s) / label(s) to hand.

YOU WILL BE CHARGED A FEE OF $15 FOR REFILL REQUEST(S) COMPLETED OUTSIDE OF AN OFFICE VISIT. THIS FEE MUST BE RECEIVED UP FRONT.

If you have difficulty completing the form, please email reception@juniper.bm with details.

Prescription Refill Request

Dr. Price will only refill prescriptions where:

1) You are a current registered patient of Juniper Medical and have had at least one appointment; and,

2) The refill(s) you are requesting has (have) been personally prescribed by Dr. Price.

Up to five (5) medications can be refilled per request. For more than 5 medications, please submit an additional request. Please be aware there is a $15 fee for all requests on a single date made outside of an office visit and payment must be received up front. To avoid this charge, it is recommended that you refill your medications during office visits, or if this isn't possible, please check ALL your medications before requesting a refill to avoid multiple charges. If you have more than five refills required, please complete and submit an additional form.

We will endeavour to complete refill requests within 72 hours, but as this is not always possible, please do not wait until you have completely run out of medications before requesting the refill.

Please consult your pharmacist for assistance if you do not have all your current prescription information to hand.

First name

Last name

Birthday

Day

Month

Year

Preferred Contact Number (enter like +14417654321)

Preferred Email

Patient Information and Registration Form