Prescription Request Form Template

About this template

Prescription Request Form is a document or tool that is used by the patient to request a new or repeat prescription for medicines. It is important that this document be accurate because the wrong medicine can cause serious problems for the patient.

This Prescription Request Form template contains form fields that ask for the patient's name, age, date of birth, and contact details. This template also verifies the physician's name, prescribed medications, pharmacy name, special instructions, confirmation, and signature. The prescribed medicines section is using the Input Table tool that uses the Multi Type Columns option. This option allows the form creator to combine different types of fields in the table. This table shows the medicine name, strength or dosage, quantity, route, and if the medicine is required or not. This form template is using the File Upload tool where the respondent can upload a photo of the prescription. Customize this simple template via the Form Builder and adjust it accordingly.