Prescription Refill Form

You may use this form to request a prescription refill. Please keep these guidelines in mind:

Do not use this form for urgent refill requests, call our office
Referrals submitted using this form can take 3 business days to process
Certain controlled substances ( ej. Ritalin, Adderall, Concerta, Metadate, Dexedrine ) cannot be called in to a pharmacy and must be picked up in person at our office or mailed to your home
School permission: Please let us know if you need a 'school permission form' for your child to take this medication while at school
Please use a separate form for each medication request

Fields marked with "«" are required.
Parent Name (First/Last) «
Child's Name «
E-mail Address
Telephone Number «
Pharmacy Name and Phone Number «
Other Pharmacy Name and Number:
Name of Medication (1) «
Other Medication:
Form of Medication «
Dose «
Reason for Administration «
Can we confirm this request by E-mail?	[ Yes ] [ No ]
Fields marked with "«" are required.