Prescription Refill Request Form​

For your convenience, please use this form to request a prescription refill online.  Note that this form is for existing patients of Belmont Medical only. 


Please submit requests for refills of your current medications only -- you cannot request a new medication using this form.  If you feel you need a new medication or need changes made to your medications, please book an appointment with your primary care provider by clicking here to submit an appointment request.



PLEASE NOTE: The cost of prescription refills by phone, fax, or online requests is NOT covered by OHIP.   There is a $25.00 fee (includes HST) charged to the patient each time this form is submitted.  Note that you can request multiple prescription refills when submitting this form, all for the same one-time fee.  Prescription renewal fees do not apply to patients greater than 70 or  under 18 years of age and fees may be waived in exceptional circumstances.



Please do not use this form to submit requests for refills of narcotics, benzodiazepines, or other controlled substances.  You will need an appointment with your doctor or a request from your pharmacist for such medication refills.  



Forms Confidentiality & Legal Disclaimer:

The forms on this website submit electronic information via email. The messages sent via email form submission and any of the information and/or files transmitted are confidential and intended solely for the use of the individual or entity to whom they are addressed. Disclosing, copying, distributing, or taking any action in reliance on the contents of this confidential information is strictly prohibited. Internet form submission via email cannot be guaranteed to be secure or error-free, as information could be intercepted, corrupted, lost, destroyed, arrive late or incomplete, or contain viruses. Belmont Medical does not accept liability for any errors or omissions in the contents of the submitted information which may arise as a result of email transmission or internet information protocols. Belmont Medical accepts no liability for the content of this email form submission, or for the consequences of any actions taken on the basis of the information provided.

Please list one medication per line.
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Thank you! Your message was sent successfully. The cost of prescription refills by phone, fax, or online requests is NOT covered by OHIP. There will be a $20 fee charged to the patient each time this form is submitted. Please allow 3-5 business days (Monday-Friday) for your prescription refill request to be processed and faxed to your pharmacy.