For all ADHD medication refills, please complete this form. Submit your request several days before your medication is needed, and allow 24 business hours for processing.

Patient Name

First Name

Last Name

Your name

Your Email

Name of medication and dosage

Pharmacy

Does your child have any of the following symptoms: chest pains, difficulty breathing, abdominal pain, poor appetite, trouble sleeping, emotional changes, or tics?

If the answer is yes please call us.

Any comments/concerns: