Quick Refill Request
Single-screen repeat prescription request with medication and dose, preferred pharmacy, collection or delivery and a note for the prescriber.
A ready-to-use healthcare & clinical form for small teams who need a reliable intake process: 10 questions, 1 page, 3 conditional rules.
- Questions
- 10
- Pages
- 1
- Layouts
- classic · card
- Time to complete
- ≈ 3 min
- Conditional rules
- 3
Searches this template answers
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.
Compliance checklist
- Payment items priced — passingEvery payment question charges a real amount, so a submission always records a payment.
- Conditional logic resolves — passingEvery rule points at a question or page that exists in this template.
- Medical disclaimer present — passingThis form does not provide medical advice, diagnosis or treatment. Information you share here is not a substitute for care from a qualified clinician. In an emergency, contact your local emergency service immediately.
- Question labels unique — passingLogic and exports address questions by label, so duplicates are ambiguous.
What happens after submit: nothing is stored in this preview. On your own copy, every response triggers an instant email notification and lands in your response dashboard, ready to export or forward.
Happy with it? Take a copy into your workspace — every question, rule and setting comes with it.
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.
About this template
Repeat prescription lines eat morning reception time, and half the calls end with the same question: which strength, and which pharmacy. This one-screen form collects both up front. The patient names each medication with its dose, says how many days they have left, and chooses the pharmacy that should receive it. The days-remaining answer is what lets a prescriptions clerk sort the queue sensibly instead of working strictly first-come, because someone with two days left is not the same as someone stocking up early. A collection-or-delivery question saves a follow-up call, and the free-text note gives space for the things that matter to a prescriber: a dose that was changed at hospital, a side effect worth mentioning, a pack size that never lasts the month. The form deliberately does not confirm anything. It is a request, and the intro says so, because the decision belongs to the prescriber reviewing the record. Once the request is logged with a reference, the patient can be told exactly when it was received rather than being asked to call back and check.
What this form asks
Every question is editable — rename it, make it optional, or delete it entirely.
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
10 questions in total.
Example of a completed prescription refill request form
A sample request showing how a patient asks for a repeat prescription and preferred pharmacy.
- Patient full name
- Helena Cross
- Date of birth
- 27/06/1990
- Contact number
- 555-484-2210
- Medications and doses needed
- Metformin 500mg, twice daily
- Days of medication left
- 4
- How would you like it dispensed?
- Collection from pharmacy
- Preferred pharmacy
- Example.com Community Pharmacy, Maple Street
- Has anything about the medication changed?
- No
Sample data — no real people, addresses or records are shown.
How the form changes as it's filled in
This template ships with 3 conditional rules, grouped into 3 behaviours driven by 2 questions. Everything below is already set up — edit or delete any rule once the template is in your workspace.
Driven by “How would you like it dispensed?”
- Makes answers required
If “How would you like it dispensed?” is Delivery, “Delivery address” becomes required before the form can be submitted.
- Makes answers required
If “How would you like it dispensed?” is Collection from pharmacy, “Preferred pharmacy” becomes required before the form can be submitted.
Driven by “Has anything about the medication changed?”
- Makes answers required
If “Has anything about the medication changed?” is Yes, “Note for the prescriber” becomes required before the form can be submitted.
Set it up step by step
- 1
Say it is a request, not a confirmation
One line above the form prevents the most common complaint: a patient assuming the prescription was issued the moment they pressed send.
- 2
Sort by days remaining
Use that answer to order the working list so people who are nearly out are seen first, and publish your normal turnaround.
- 3
Ask for strengths, not brand guesses
The dose line is where errors creep in, so tell patients to copy the label rather than describe the packet.
- 4
Send a reference back
An automatic confirmation with a reference number removes almost all "did you get it?" calls.
Mistakes to avoid
- Letting the form imply approval, so patients arrive at the pharmacy before anything has been issued.
- Skipping the pharmacy question and then phoning every patient to ask it.
- Treating the free-text note as optional reading, when it is often where a changed dose is mentioned.
What it pairs with
Most teams don't run this form on its own. These are the forms and systems it sits next to.
What to do with the responses
Work the list in order of days remaining, pass anything with a flagged change to the prescriber first, and confirm to the patient once the request has actually been issued.
Works in both layouts
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Privacy & compliance
This form collects health information. Keep access limited to the people who need it, turn on encrypted answers for the clinical questions, and set a retention window so records don't sit in the dashboard forever.
Frequently asked questions
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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