Quick Refill Request — shared by the community
Tom H. shared this 10-question build with 3 conditional rules already wired up. Test it below, then take a copy.
A ready-to-use healthcare & clinical form for small teams who need a reliable intake process: 10 questions, 1 page, 3 conditional rules.
- Shared by
- Tom H. · Agency owner
- Questions
- 10
- Replies
- 4
- Copies taken
- 233
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Live preview and test console
This is the real form. Answer it to test the flow — nothing is sent or stored.
This template runs as a straight sequence — no branching rules.
Works for you? Take Tom H.'s copy into your own workspace — questions, rules and settings included.
Who this template is for
Quick Refill Request is built for small teams who need a reliable intake process who need to collect the same complete information from everyone.
- Small teams who need a reliable intake process working in healthcare & clinical.
- Teams who need to collect the same complete information from everyone without writing code or paying for a custom build.
- Anyone replacing chasing missing details over email with one structured record per enquiry.
- Respondents are the people you send it to — the form asks them 10 questions across 1 screen.
- Mobile-heavy audiences, thanks to the one-question-per-screen card layout.
Why this form is useful
It removes the cost of chasing missing details over email and turns each submission into a record your team can act on immediately.
- 7 questions are required, so submissions arrive complete instead of needing a follow-up email.
- It captures a phone number for urgent follow-up.
- It pins the request to a specific date.
- It captures a full postal address.
- It captures a numeric value you can filter and sort on.
- Conditional logic hides 3 questions until they are relevant — shorter forms convert better than long ones.
- Every response is stored, searchable and exportable, so nothing depends on one person's inbox.
How to use this template
From copy to live form is a few minutes of work, and every step is reversible.
- 1Press “Use this template” — a fresh copy of Quick Refill Request lands in your workspace, ready to edit.
- 2Rename or delete any question, and change what is required. Nothing here is fixed.
- 3Open Notifications and add the email addresses that should be alerted on each submission; add an auto-reply to the respondent if the form collects an email address.
- 4Publish it, then either share the link directly or paste the embed snippet into your site — the embedded form resizes to fit and loads no marketing or advertising trackers.
- 5Watch responses land in Submissions, where you can filter, label and export them to CSV or PDF.
Logic and conditions blueprint
Exactly how this form behaves as it is answered — 3 conditional rules ship with it.
- Features conditional validation: if “How would you like it dispensed?” is Delivery, “Delivery address” becomes mandatory before the form can be sent.
- Features conditional validation: if “How would you like it dispensed?” is Collection from pharmacy, “Preferred pharmacy” becomes mandatory before the form can be sent.
- Features conditional validation: if “Has anything about the medication changed?” is Yes, “Note for the prescriber” becomes mandatory before the form can be sent.
- All 3 rules are editable in the Logic tab, and the built-in checker warns about rules that contradict each other.
What this form asks
Refill request
- Patient full namerequired
- Date of birthrequired
- Contact numberrequired
- Medications and doses neededrequired
- Days of medication leftrequired
- How would you like it dispensed?required
- Preferred pharmacy
- Delivery address
- Has anything about the medication changed?required
- Note for the prescriber
Conditional logic in this build
- When “How would you like it dispensed?” is Delivery, require “Delivery address”.
- When “How would you like it dispensed?” is Collection from pharmacy, require “Preferred pharmacy”.
- When “Has anything about the medication changed?” is Yes, require “Note for the prescriber”.
Questions about this shared form
Does this replace a medication review?
No. It handles the routine request only; when a dose needs looking at properly, use the Medication Review Form, which asks about adherence, side effects and what the patient wants to change.
What if the patient does not know the strength?
Ask them to copy the label wording into the medication box. It is better to receive an imperfect line the prescriber can check than a brand name with no dose at all.
Can we limit it to existing patients?
Yes. Name and date of birth are enough to match the record, and any request that does not match should be handled as a query rather than filled.
How do we handle controlled medication?
Keep it out of this form and say so in the intro; those requests need your own identity and prescriber process rather than an online line.
Is the Quick Refill Request template free to use?
Yes. You can preview and test Quick Refill Request on this page without an account, and take a copy into your own HelloForms workspace on the free plan. There is nothing to install and no card required to publish it.
What does the Quick Refill Request template ask for?
It asks 10 questions across 1 page, 7 of which are required. Every question is listed in full further down this page, and each one can be renamed, reordered, made optional or deleted after you copy the template.
Can I edit the Quick Refill Request form after copying it?
Yes — the copy is entirely yours. Change wording, add or remove questions, switch between the classic and card layouts, restyle it to match your brand, and set who gets notified on each submission.
How does the conditional logic in this healthcare & clinical form work?
3 conditional rules ship with the template: Features conditional validation: if “How would you like it dispensed?” is Delivery, “Delivery address” becomes mandatory before the form can be sent. Features conditional validation: if “How would you like it dispensed?” is Collection from pharmacy, “Preferred pharmacy” becomes mandatory before the form can be sent. Features conditional validation: if “Has anything about the medication changed?” is Yes, “Note for the prescriber” becomes mandatory before the form can be sent. All rules are editable in the Logic tab.
Where do responses to the Quick Refill Request form go?
Submissions land in your workspace under Submissions, where you can search, filter, label and export them to CSV or PDF. You can also email a notification to your team on every submission and send the respondent an auto-reply.
Can I embed the Quick Refill Request form on my own website?
Yes. Publish the form and paste the embed snippet into any page or share the direct link. The embedded form resizes to fit its container and loads no advertising or marketing trackers inside the iframe.
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