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If the medication is not ready at your pharmacy 3 business days after you submit a refill request:

⒈ Confirm with your pharmacy that:

        🔵 Dr. McCarthy's request has been received (pharmacy backlogs sometimes prevent this)
        🔵 The medication is in stock

⒉ Keep Dr. McCarthy updated (703-288-3535)

REFILL REQUEST FORM

Please note: only requests that follow the                       will be considered.

 = required information

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IMPORTANT:

The medication "shortage" has caused a surging volume of resubmissions and extensive additional processing time. As a result of this unfortunate national situation, refill requests now require 3 business days' notice to process.

Patient

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Who is completing this form?

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Medication

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Days Supply

(as authorized by treatment plan and insurance)

Pharmacy

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This area is reserved. It is ONLY IF NECESSARY
for specific prescription details and refill information.
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It is not for clinical questions or any other comments and is NOT a way to reach Dr. McCarthy. Instead, call her office (703-288-3535) and leave her a confidential message.

Message (ONLY IF NECESSARY)

Message (ONLY IF NECESSARY)

Required Acknowledgements

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If outside required 3-month appointment window

Success! Your request has been submitted

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