For ADHD refills, please submit this form several days before the medication is needed. We can only send the prescription 27 days after the last one was filled, and it must be picked up within 72 hours.

Patient Name

First Name

Last Name

Your name

Your Email

Name of medication and dosage

Pharmacy

We would like to check in monthly to make sure your child has none of the following symptoms. Please review and let us know if you note any of these in your child: chest pain, difficulty breathing, abdominal pain, poor appetite, difficulty sleeping, emotional lability, and tics.

If the answer is yes please call us.

Any comments/concerns: