REFILL REQUEST FORM

Please note that only requests that follow the Refill Policy will be considered.

= required information

*

Refill requests are reviewed during business hours only ( M-F 7:30-5:30) and require 48 hrs business day notice to process.

Patient

*

Patient first name

Patient last name

*

Patient Date of Birth

Who is completing this form?

*

Requester Full Name

*

Requester Relation

Requester Phone

Requester Email

*

Medication

*

Medication Name

Dose (mg/ml)

*

Days Supply

30 days

90 days

(as authorized by treatment plan and insurance)

Pharmacy

*

Pharmacy Name

*

Pharmacy Phone

*

Pharmacy Street Address

*

Pharmacy City

Pharmacy State

Pharmacy Zip

*

Message (ONLY IF NECESSARY)

This area is reserved. It is ONLY IF NECESSARY
for specific prescription details and refill information.

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.

Required Acknowledgements

I understand and agree to the refill policy in its entirety.Refill Policy

*

I understand and agree that a $25 refill processing fee will be billed to my account when the refill is submitted.

*

I am outside of the required three-month appointment window necessary for Dr. McCarthy to prescribe, and I need to be put on her wait list for an appointment as soon as possilble.

If outside required 3-month appointment window

*

CATHERINE MCCARTHY, MD

REFILL REQUEST FORM

Please note that only requests that follow the Refill Policy will be considered.

*

Patient

*

*

*

Who is completing this form?

*

*

*

*

Medication

*

*

*

Pharmacy

*

*

*

*

*

*

Message (ONLY IF NECESSARY)

This area is reserved. It is ONLY IF NECESSARY
for specific prescription details and refill information.

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.

Required Acknowledgements

*

*

If outside required 3-month appointment window

*

CATHERINE MCCARTHY, MD • 6723 WHITTIER AVENUE, SUITE 403 • MCLEAN VA 22101 • 703.288.3535

©2022 Catherine McCarthy, MD

CATHERINE MCCARTHY, MD

REFILL REQUEST FORM

Please note that only requests that follow the Refill Policy will be considered.

*

Patient

*

*

*

Who is completing this form?

*

*

*

*

Medication

*

*

*

Pharmacy

*

*

*

*

*

*

Message (ONLY IF NECESSARY)

This area is reserved. It is ONLY IF NECESSARY for specific prescription details and refill information.

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.

Required Acknowledgements

*

*

If outside required 3-month appointment window

*

This area is reserved. It is ONLY IF NECESSARY
for specific prescription details and refill information.