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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

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

Date

If signed by guardian/representative

Name

Relationship to Patient

Representative Signature

Date

Thank you for your request. We aim to process refill requests within 2 business days.

Workflow: Print/Preview your completed form → Save a PDF copy → Submit & upload to our secure Dropbox.

Ready

As a dedicated dental hygienist at Amazing Smiles Teledentistry, Rebecca Reifert provides the best online consultations by offering expert preventive care, personalized oral hygiene advice, and professional support—all from the comfort of your home

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Contact Info

Anytown, USA

rebecca@deltadentalsmiles.live

(810) 712-7175

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