Medication Refill Request

To request a medication refill, please complete the form below.

* Note: If you missed your last medication appointment, there is a $25 refill fee and a standard medication appointment required before your refill will be processed.*

Your name (required)*

If you are alright with us emailing you, please provide your E-mail Address*

Your phone number*

Your pharmacy name

Pharmacy address

Pharmacy phone number

Medication name:*

Medication dosage*

By clicking SEND below you are consenting to sending personally identifying information. Please call if you prefer to provide it over the phone.

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Requests received Friday - Sunday will be processed on the following Monday.

If you need additional assistance, please contact us at: (865) 983-1899 office@knoxbehavioral.com

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