Prescription Refill Request

A patient who needs a refill wants to type the medication name and move on with their day. The pharmacy or clinic taking that request wants it to arrive complete: the right drug, the right dosage, the prescriber attached. This template serves both sides. Patients finish it in an estimated 3 to 5 minutes, and it's free to use on Uplup.

Nine fields, one complete request

The form runs two content pages and closes with an ending page, with 9 fields in total. Required entries keep the essentials from slipping through: full name, email, Medication Name, Dosage, and Prescribing Doctor all have to be filled in before the form submits. Phone number, date of birth, and preferred pharmacy stay optional, so a returning patient isn't held up by details you may already have on file. The final decision is a required choice, "Need delivery?", with two options: Pickup or Delivery.

Every field is editable. If your workflow needs an insurance ID, an allergy note, or a refill quantity, add it in the editor. The template also recommends conversational mode, which presents one question at a time, a pace that suits a patient filling this out on a phone with a pill bottle in the other hand.

From voicemail pile to fill queue

Each submission lands in your Uplup dashboard as a structured record instead of a garbled message on the refill line. Per-question breakdowns surface patterns worth acting on: how many requests name a pharmacy, how the Pickup versus Delivery split runs week to week, which prescribers generate the most refill traffic. Export everything to CSV for your records, or push each new request to your own systems through webhooks or Zapier so the front desk sees it the moment it arrives.

Meeting patients where the request starts

A refill request usually begins at home, not at the counter. Share the form as a direct link in appointment reminders, print the QR code on bags or receipts so the next refill is one scan away, or place it on your site with the embed snippet or the WordPress shortcode from the Uplup plugin. Back navigation lets a patient who taps the wrong option step back and correct it before submitting. Add your logo and colors so the page reads as your pharmacy, not a generic form.