Medication Refill

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BaliDoc Fast-Track Medication Refill

Complete this form to request a refill of your ongoing medication. Our medical team reviews every submission to make sure your prescription is issued safely. No account or login is needed. In a medical emergency, call 112 or go to the nearest hospital.

Section 1 · Identity & travel verification

Full name (as shown on your passport / ID card) * Date of birth *

WhatsApp number *

Email address *

Used for prescription delivery & updates.

What type of medication are you refilling? *

Non-psychiatric Psychiatric

Non-psychiatric = blood pressure, diabetes, gout, acid reflux, asthma, birth control, etc. Psychiatric = antidepressants, anti-anxiety, sleep, ADHD, or similar medication.

Section 2 · Medication details & refill request

Name of medication & dosage required * Photo of your current medicine packaging / bottle (optional) Supporting medical document / previous prescription (optional) How many days of refill do you need? *

3 days (emergency) 7 days 14 days 30 days (max) Other / need advice

This fast-track service is for ongoing chronic or long-term conditions (high blood pressure, diabetes, gout, acid reflux, asthma, birth control, etc.). Strict-duration medications (antibiotics, antivirals, steroids) are not automatically refilled — their prescription and duration are subject to our doctor's clinical assessment.

What condition / illness are you taking this medication for? *

Section 3 · Essential health & safety screening

How long have you been taking this medication continuously? *

Less than 1 month 1–6 months More than 6 months

Any new or unusual symptoms, or side effects from this medication? *

No — I feel fine, just need a refill Yes

Please describe briefly

Any known severe allergies to medications? *

No Yes

Please list your medication allergies

For female patients — are you currently pregnant or breastfeeding? *

No Yes Not applicable

Safety check — are you currently experiencing any acute or severe symptoms? (severe chest pain, sudden shortness of breath, high fever, severe dizziness, loss of consciousness) *

No Yes

🛑 If you are experiencing acute or severe symptoms, please do not rely on this refill form — contact emergency services now, or request an immediate Doctor Home Visit. You may still submit; it will be marked URGENT and prioritised.

Section 4 · Additional information & consent

Anything else that would help us provide the safest care? (optional) Upload recent lab results / medical reports (optional)

I confirm that I am requesting a refill for a medication previously prescribed to me. I understand that BaliDoc doctors will review my health details and reserve the right to decline or request a full consultation if the refill is deemed medically unsafe. *

This form is for travellers needing a temporary supply of their ongoing psychiatric medication. Because of medical regulations, every submission is reviewed by our medical team.

Section 1 · Identity verification

Clear photo of your passport or ID * Selfie holding your passport / ID next to your face *

Section 2 · Prescription & refill request

Official supporting medical document * — a doctor's prescription, medical resume, or formal doctor's note from your home country Current psychiatric medication name & dosage * Photo of your current medicine packaging / bottle (optional) Are you currently taking any OTHER non-psychiatric medications, antibiotics, or supplements? *

No Yes

Please list them (e.g. "Azithromycin", "Omeprazole", "Ibuprofen")

Any known severe allergies to medications, food, or substances? *

No Yes

Please list them (e.g. "Penicillin, Sulfa drugs, Aspirin")

How long have you been taking this exact medication and dosage? *

Less than 1 month 1–6 months More than 6 months

When was your last dose taken? * How many days of refill do you need until you return home / see your primary doctor? *

3 days (emergency) 7 days 14 days 30 days (max)

Primary doctor / psychiatrist in your home country (optional — name of doctor/clinic)

Section 3 · Mandatory safety screening ⚠️

Please answer truthfully.

A. Are you currently experiencing any thoughts of self-harm, suicide, or harming others? *

No Yes

B. Severe worsening of symptoms, severe agitation, hallucinations, or a mental health crisis? *

No Yes

🛑 If you are in a mental health emergency, please visit the nearest Emergency Room or contact local emergency services immediately. You may still submit — it will be marked URGENT and prioritised — but a form is not a substitute for emergency care.

C. Severe withdrawal symptoms from missing doses? (brain zaps, severe dizziness, extreme rebound anxiety, nausea) *

No Yes

D. Currently consuming alcohol or non-prescribed / recreational substances while taking this medication? *

No Yes

E. Requesting a refill for controlled substances (strong sleeping pills, benzodiazepines, stimulants / ADHD meds) without active guidance from a doctor? *

No Yes

What happens next: our medical team will carefully review your details. If your answers indicate any safety risks, severe symptoms, or complex needs, our doctor will reach out to guide you through a brief consultation before any medication can be safely issued.

Section 4 · Additional information & consent

Any additional medical information or symptoms you'd like the doctor to know? (optional)

I confirm that I am a traveller requiring a temporary refill of my ongoing prescribed medication. All information provided is truthful, and I understand that BaliDoc doctors reserve the right to review my request and recommend a full consultation if deemed necessary for my safety. *

Your information is sent securely to BaliDoc's private Google Workspace. It is not stored on this website.

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Your refill request has been received

Our medical team will review it and contact you on WhatsApp or email. Thank you.

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BaliDoc Fast-Track Medication Refill

Your refill request has been received