--- title: Peripheral Artery Disease Medication Refill Request Form Template | Paperform description: Streamline PAD medication refills with this comprehensive form template including ABI results, walking distance logs, and vascular surgery review for healthcare providers. url: "https://paperform.co/templates/peripheral-artery-disease-medication-refill-request" type: static generatedAt: "2026-04-04T00:44:49.749Z" --- [← Back to free form templates](/templates/) ![Peripheral Artery Disease Medication Refill Request](https://img.paperform.co/fetch/f_webp/https://d3gw2uv1ch7vdq.cloudfront.net/content/form_templates/assets/peripheral-artery-disease-medication-refill-request.png) [Preview](https://_preview.paperform.co/ai-template/peripheral-artery-disease-medication-refill-request) [Use this template for free](/create?ai-template=peripheral-artery-disease-medication-refill-request) [Healthcare & Medical Forms](/templates/category/healthcare/) [Healthcare](/templates/industry/healthcare/) [Physician](/templates/role/physician/)[Nurse](/templates/role/nurse/)[Healthcare Administrator](/templates/role/healthcare-admin/) About this free form template Managing peripheral artery disease (PAD) requires consistent medication adherence and regular monitoring of symptoms and vascular health. This **Peripheral Artery Disease Medication Refill Request** template streamlines the refill process for healthcare providers and patients, ensuring that all critical health markers are captured before renewing prescriptions. Designed specifically for vascular clinics, cardiology practices, and primary care providers managing PAD patients, this form collects essential information including current ankle-brachial index (ABI) measurements, walking distance logs, symptom progression, and medication compliance history. By gathering this data upfront, healthcare teams can make informed decisions about medication adjustments and identify patients who may need urgent vascular intervention. The form includes conditional logic that adapts based on symptom severity, automatically flagging patients who report worsening claudication, rest pain, or concerning ABI values for immediate physician review. This intelligent workflow helps prioritize cases that may require vascular surgery consultation while processing routine refills efficiently. **Paperform** makes it easy to customize this template to match your practice's specific protocols and medication formulary. Integrate with your electronic health record system via **Stepper** to automatically create chart notes, update medication lists, and trigger appointment scheduling for patients due for follow-up visits. You can also set up automated confirmation emails with medication pickup instructions and lifestyle modification resources. For practices requiring documented patient consent for refills or those implementing value-based care programs, this template provides a complete audit trail of patient-reported outcomes and clinician review, supporting both compliance requirements and quality metrics for PAD management. Built for growing businesses, trusted by bigger ones. 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