Prescription Request Form  Non-controlled Rx Prescriptions should be called to your pharmacy that in turn will send us a fax. The information on the fax form will be verified. The signed fax will be returned to pharmacy. Please allow 3 working days. The only exception from this rule is Accutane that must be re-written every time. Controlled (requiring separate triplicate forms) prescriptions may take up to seven days. Patients and parents can fill out the form on this page for all types of prescriptions and will be faxed to us at (999) 555-1111. These requests can also be mailed via USPS. All medication requests and updates will be received by the office in fax format and checked the same day or the next business day but not on the weekends. Please note that the patient must be seen regularly as scheduled by prescribing physician for uninterrupted refill of prescriptions. If the patient has not been seen recently, only one-week supply will be provided. A field with an asterisk (*) is required. When you have completed the form, please press the "Preview" button to Preview your request. Doctor's Name :: Michael Dolittle, MD Steven Spock, MD Michelle Poppins, MD Other not Listed Requester's Name* :: Address* :: City* :: Zip Code* :: State* :: AL - Alabama AK - Alaska AZ - Arizona AR - Arkansas CA - California CO - Colorado CT - Connecticut DC - Washington, DC DE - Delaware FL - Florida GA - Georgia HI - Hawaii ID - Idaho IL - Illinois IN - Indiana IA - Iowa KS - Kansas KY - Kentucky LA - Louisiana ME - Maine MD - Maryland MA - Massachusetts MI - Michigan MN - Minnesota MS - Mississippi MO - Missouri MT - Montana NE - Nebraska NV - Nevada NH - New Hampshire NJ - New Jersey NM - New Mexico NY - New York NC - North Carolina ND - North Dakota OH - Ohio OK - Oklahoma OR - Oregon PA - Pennsylvania RI - Rhode Island SC - South Carolina SD - South Dakota TN - Tennessee TX - Texas UT - Utah VT - Vermont VA - Virginia WA - Washington WV - West Virginia WI - Wisconsin WY - Wyoming Requester's Daytime Phone* :: Alternate Phone :: Patient's Name (if Different) ::   Patient's Birthday* :: Email Address* :: Pharmacy Name, Phone :: FAX to Number :: ____________________________________________________ Medication 1*:   Select Medication? Aderall Concerta Dexadrine Focalin Metadate Ritalin Other not Listed -->   Dosage*:   Taken How Often*:   Quantity Requested*:   Prescription*:  Mail   Requester Pickup Call Requester when ready        Date Needed By*:    ASAP ___________________________________________________ Medication 2 :   Select Medication? Aderall Concerta Dexadrine Focalin Metadate Ritalin Other not Listed -->   Dosage:   Taken How Often:   Quantity Requested:   Prescription:  Mail   Requester Pickup Call Requester when ready        Date Needed By:       ASAP ___________________________________________________ Medication 3 :   Select Medication? Aderall Concerta Dexadrine Focalin Metadate Ritalin Other not Listed -->   Dosage:   Taken How Often:     Quantity Requested:   Prescription:  Mail   Requester Pickup Call Requester when ready        Date Needed By:       ASAP ___________________________________________________ Medication 4:   Select Medication? Aderall Concerta Dexadrine Focalin Metadate Ritalin Other not Listed -->   Dosage:   Taken How Often:     Quantity Requested:   Prescription:  Mail   Requester Pickup Call Requester when ready         Date Needed By:       ASAP ___________________________________________________ How is the patient currently doing? Please tell us everything that is important about the patients condition.  Also provide any special instructions about this Rx refill request. Comments: If this is a controlled medication, the Rx will be mailed to your home unless alternate directions are requested. If it is not a controlled drug, the Rx will be called or faxed to the Pharmacy. Controlled Rx must be filled within 14 days. Rewriting an expired Rx is subject to $15 charge. PLEASE NOTE: Not keeping scheduled appointment can delay or interrupt refill of you or your child's prescriptions.