Your Smile Partners PLLC — Teledentistry Prescription Refill Request Form Teledentistry Prescription Refill Request Form Your Smile Partners PLLC 99 Wall St, New York, NY 10005 Email: talk@yoursmilepartners.com Phone: (212) 555‑SMILE Step 1: Print/Preview Step 2: Save PDF Step 3: Submit & Upload Print / Preview Save PDF to Device Submit & Upload to Dropbox Clear All Fields Please complete this form in full to request a prescription refill. Your responses help us ensure safe and appropriate medication management. 1. Patient Information Full Name Date of Birth Address City State ZIP Phone Preferred Contact Phone SMS Email Email Address 2. Prescription Information Medication Name Strength (e.g., 500 mg) Form (e.g., tablet, gel, rinse) Current Dosage & Frequency Original Prescription Date Prescription Number (if known) Pharmacy Name Pharmacy Phone Reason for Refill Request 3. Symptom & Oral Health Screening Are you currently experiencing any of the following? (Check all that apply) New or worsening pain at treatment site Swelling of gums, face, or jaw Bleeding from gums or oral tissues Ulcers, sores, or lesions in mouth Increased sensitivity to hot/cold/sweet Dry mouth or excessive salivation Difficulty swallowing or speaking Other Symptom severity (0 = none; 10 = worst) 0 10 0 New medications/supplements since last visit? Yes No Known allergies or adverse reactions? Yes No New medical condition since last visit? Yes No Currently pregnant or breastfeeding? Yes No N/A 4. Medication Use & Compliance I have been taking medication as directed No Sometimes Side effects experienced (check all that apply) Nausea or vomiting Dizziness or lightheadedness Rash or itching Gastrointestinal upset Headache Other Do you have enough medication to last until the refill is processed? Yes No 5. Follow‑Up & Care Plan Do you require a telehealth consultation before approval? Yes No Schedule a follow‑up teledentistry appointment? Yes No Preferred time Morning Afternoon Evening Questions or concerns about medication or treatment plan 6. Authorization & Signature The practice will review my request and may contact me for further assessment. Approval of a refill request is at the discretion of the prescribing provider. If clinical evaluation is required, I may be asked to schedule a virtual or in‑office visit. I certify the information is accurate and complete. Patient Signature Clear Date If signed by guardian/representative Name Relationship to Patient Representative Signature Clear Date Thank you for your request. We aim to process refill requests within 2 business days. Ready
