Medication Refill Request · Dr. Blinkhorn & Dr. Whiting Family Practice

Before you fill in this form

Your family doctor needs to check in with you periodically when you are on prescription medication.

Medications are usually prescribed to last until your next check-up is due. This is intentional — it is your doctor's way of making sure you get the monitoring your condition requires. This is a feature, not a bug.

If you think your doctor has simply forgotten to renew your prescription, please go ahead and fill in the form below and we will take a look.

If your medication has run out: your pharmacy can usually provide an emergency supply to tide you over until your appointment.
If you are due for a check-up: please book an appointment online — your physician will address the refill at your visit.

There was a problem submitting your request. Please try again or call the clinic at 250-860-1622.

Patient Information

Full Name *

Date of Birth *

Health Card Number (CPN) *

Phone Number *

Medication Details

Please refill all of my regular medications Check this if you need all your usual prescriptions renewed at once. Your physician will review your full medication list.

— or list specific medications below —

Medication 1

Medication Name *

Dose (if known)

Pharmacy Name & Location *

Follow-Up

Approximately when did you last see your physician for this condition?

Do you think you are due for a follow-up appointment?

Additional information for your physician (optional)

Submitting your request...