ADD/ADHD Prescription Refill Request


ID:
 
Date of Birth:
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When requesting prescription refills, please answer the following questions and submit this form online. Please list a phone number where you can be reached or where we can leave you a message. If you do not hear from us within 72 hours, you may come by the office and pick up the requested prescription.

Date of Patient's Last Physical:
Calendar
Date of Patient's Last Office Visit:
Calendar
 
 

Has your child experienced any side effects while taking this medication?:
Has your child's appetite changed while on this medication?:
Has your child lost weight since taking this medication?:
Has your child complained of stomach aches while taking this medication?:
Has your child had headaches while on this medication?:
Has your child had sleep problems while on this medication?:
Have you noticed changes in your child's mood while on this medicine?:
Has your child's behavior altered while on this medication?:
Does your child behave differently when not taking this medication?:
Does taking this medication make your child feel tired?:
Does your child have tics while on this medication?:
Does your child experience any other problems while taking this medication?:


Parent or Guardian

For Office Use Only
 









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