Prescription Refill Request Form

You may use this page to submit an online request to refill a prescription. A request for a NEW medication should be requested by phone.

  • A request to refill your child's prescription will be handled on a "first come" basis.
  • Each medication requires a new request form to be submitted.
  • We attempt to refill your child's prescription within 24 hours.

Requests for stimulant medications (Ritalin, Adderall, Concerta, etc.) require a written prescription that must be picked up (or mailed) from your provider's office. Allow 2-4 days for stimulant prescriptions.



Patient Information




Date of Birth:
CalendarNow



Guardian Information




* Telephone number(s) you can be reached at during the day.:

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Prescription Information

NOTE: All Class II medications (Ritalin, Adderall, Concerta, Metadate,etc) must be picked up at the office:


 
 

If Send to Pharmacy

 

 
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Authorization


Electronic Signature

By entering my name below, I understand that I am providing an electronic signature which will serve as an affirmation that I'm the parent/legal guardian of the patient entered above.:






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