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Have a Question?

We’re Here to Help

The refill form is the fastest way to request a refill. If you have a question about your prescription or the process, our care team is happy to help:

Phone: (914) 415-5546
Email: care@protocolhealthmd.com

For your safety, some medications require up-to-date labs or a follow-up visit before a refill can be approved. Our team will let you know if anything is needed.

Medication Refill Request Form

Please complete this form when you need a refill of your current medications. Fields marked * are required.

Patient Information

So we match the request to your chart.

Shipping Location

Has your shipping address changed since your last refill?

Medication & Dosage

Which medication(s) do you need refilled?
Medication 1

As written on your label, e.g. 25 units weekly

Do you have a dose adjustment preference?

Clinical Information

In pounds

Have you had any recent changes to medical, lifestyle, or surgical history since your last visit?

Questions & Support

Do you have any questions about your medications you'd like to discuss with a provider?

Billing & Services

Would you like to change your billing plan with this refill?
Other services you’re interested in learning about

Your answers go securely to the Protocol Health care team.