: Monday to Friday : 8am to 5pm

Search for:

The Best Mental Health Service Provider in Texas

200 Westpark Way, Euless, TX 76040

Make an Appointment 817-488-8998 817-488-8998

Home
Our Resources
Contact Us
Patient Portal
Make An Appointment

Refill Request

Mid Cities Psychiatry
Refill Request

Make A Request!

Please Choose Below The Request Type

It is imperative that you schedule an appointment with us prior to requesting a refill.
Would you like to schedule an appointment now?

Yes

It appears your last appointment was over three months ago.
To proceed with a refill, kindly schedule an appointment with us. Would you like to schedule the appointment now?

Yes

We apologize for the inconvenience, at this time we will not be able to fulfill your refill request

OK

This field is hidden when viewing the form
Date
MM slash DD slash YYYY
This field is hidden when viewing the form
Date Submitted
- Certain Refill Requests may not be processed without an appointment with the Provider.
- Please allow at least 5 Business Days to process refill requests. There’s a $25.00 charge to process a refill request in less than 5 Business Days.
- Refill Requests will be processed for:
- For questions and/or concerns about the Refill Requests, please feel free to directly send a secured message to the provider’s Medical Assistant by clicking the Patient Portal below.
Patient Portal
I Agree*
- I Agree
This field is hidden when viewing the form
Section Break
Is your medication refill request specifically for controlled substances?*
- Yes
- No
This field is hidden when viewing the form
Section Break
Please confirm the date of your most recent Meds Management appointment at Mid Cities Psychiatry?*
MM slash DD slash YYYY
My Contact Information
Patient's Last Name*
This field is hidden when viewing the form
Date of Birth*
MM slash DD slash YYYY
Date of Birth*
Month
Day
Year
This field is hidden when viewing the form
Date of Birth copy
This field is hidden when viewing the form
Age*
We apologize for the inconvenience, we only see patients 16 years of age or older.
Do You Have A New Phone #?*
- Yes
- No
This field is hidden when viewing the form
Section Break
New Phone #*
This field is hidden when viewing the form
Section Break
Same Phone #*
This field is hidden when viewing the form
Section Break
Do You Have A New Email?*
- Yes
- No
This field is hidden when viewing the form
Section Break
New Email*
This field is hidden when viewing the form
Address
Have you moved?*
- Yes
- No
New Address
City*
Street Address*
State*
State
Zip/Postal Code*
Please upload if you have a new Driver's License
Please provide the front image of your Driver's License in PDF format
Accepted file types: pdf, jpg, jpeg, Max. file size: 120 MB.
Please provide the back image of your Driver's License in PDF format
Accepted file types: pdf, jpg, jpeg, Max. file size: 120 MB.
Please Note: There may be a slight delay of 1-2 minutes in processing your attachments based on their sizes. You're requested only to attach them once and wait for them to load.
Your understanding is greatly appreciated.
This field is hidden when viewing the form
Section Break
Do you have new insurance?*
- Yes
- No
This field is hidden when viewing the form
Section Break
New Insurance*
Other Insurance*
Please upload your Insurance card
Please provide the front image of your Insurance Card in PDF format
Accepted file types: pdf, jpg, jpeg, Max. file size: 120 MB.
Please provide the back image of your Insurance Card in PDF format*
Accepted file types: pdf, jpg, jpeg, Max. file size: 120 MB.
Please Note: There may be a slight delay of 1-2 minutes in processing your attachments based on their sizes. You're requested only to attach them once and wait for them to load.
Your understanding is greatly appreciated.
This field is hidden when viewing the form
Section Break
Do you have new secondary insurance?*
- Yes
- No
This field is hidden when viewing the form
Section Break
New Secondary Insurance*
New Secondary Insurance ID #*
Secondary Insurance Group #*
This field is hidden when viewing the form
Section
Provider's Name*
Refill Request
Medication*
Dosages
Preferred Pharmacy
(for different medications to be filled by different pharmacies, please complete additional Refill Request Form for each pharmacy)
Pharmacy Name*
Street Address*
City*
State*
State
Zip/Postal Code*
Pharmacy Phone #*
Do you have an Additional Refill Request?*
- Yes
- No
Refill Request 2
Medication*
Dosages
Preferred Pharmacy 2
Preferred Pharmacy*
New Preferred Pharmacy 2
Pharmacy Name*
Street Address*
City*
State*
State
Zip/Postal Code*
Pharmacy Phone #*
This field is hidden when viewing the form
Section Break
Do you have an Additional Refill Request?*
- Yes
- No
Refill Request 3
Medication*
Dosages
Preferred Pharmacy 3
Preferred Pharmacy*
New Preferred Pharmacy 3
Pharmacy Name*
Street Address*
City*
State*
State
Zip/Postal Code*
Pharmacy Phone #*
This field is hidden when viewing the form
Section Break
Please call us at 817-488-8998 Ext. 3 if your medication is not filled within 4-5 business days.
Please Note; processing your form may take 1-2 minutes. To avoid delays, kindly press the submit button Only Once and wait for the thank you message.
We appreciate your patience.
This field is hidden when viewing the form
Please select your Prescriber*

Δ

Contact Us!

200 Westpark Way, Euless, TX 76040

(817) 488-8998

(855) 295-2686

Monday – Friday, 8 am-5 pm

1323 E Franklin Street, #102 Hillsboro, TX 76645

(254) 266-6262

(855) 295-2686

Monday – Friday, 8 am-5 pm

About Mid Cities Psychiatry

Mid Cities Psychiatry specializes in the diagnosis, treatment and mental health issues, including substance use disorders. We are qualified to assess both the mental and physical aspects of psychological disturbance.

National Suicide Prevention Lifeline

Menu Links

Home
About Us
Services
Insurance
Forms
News
Blog
Helpful Links
Careers
Contact
Patient Portal
Gallery
Reviews

Recent Posts

Mid Cities Psychiatry is proud to introduce Philip Lafontaine, MPAS, PA-C
EMDR Therapy: What It Is and How It Benefits Your Mental Health
Mid Cities Psychiatry gleefully introduces the addition of Dr. Ashley Ibbotson, PhD, into our devoted band of mental health professionals.
Mid Cities Psychiatry is proud to introduce Triet M. La DO, MS

Categories

Addiction
Anxiety
Awareness
Bipolarity
Health Basics
Inspirational
Lifestyle
Mental Health
Personal Development
Personality Disorder
Psychosis/Psychotic Disorder
Relationships
Self-meditation
Stress and Anxiety
Well-being

© Copyright 2025. All Rights Reserved

We sincerely appreciate your kind words! Your opinion is highly valued and motivates us to continuously deliver the highest quality of patient care. If you have a moment, we would greatly appreciate it if you could share your feedback on popular review sites like Google, Yelp, or Facebook. Your review would be immensely helpful in informing others about your positive experience with us. Thank you again for your support!