Medication Refills

This form should be used to request refills for medications used for long-standing medical conditions (for example, ADHD or asthma). Your physician must have previously prescribed these medications. Online requests for antibiotics will not be honored.

* Required Fields  

*Select your doctor

*How would you like your prescription processed?
(ADHD medications cannot be phoned to pharmacies)

If you pick up your prescription, when would you like it available?

Pharmacy name/phone number, if needed

*Prescription name #1

Dosage (10 mg, 20 mg, etc.)

Frequency (once a day, twice a day, etc.)

Prescription name #2

Dosage (10 mg, 20 mg, etc.)

Frequency (once a day, twice a day, etc.)

Comments:

*Patient name:

*DOB:

*Contact name:

*Home address for prescription verification

*Call back phone number:

*Contact email address for confirmation:

 

 


 

Terms Of Use
Terms of Use

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Terms of Use

If you choose to communicate with Pediatric Associates (PA) via the web, you agree to the following:

  1. Email is not to be used for emergencies or time-sensitive issues.  Email is provided as a convenience to our patients.
  2. Communication is for established patients of PA only.  If it cannot be confirmed by our staff that your child is a patient of our office, your communication will be ignored.
  3. Secure email is not 100% secure.  An unintended recipient may view any information sent via email.  PA will not be held accountable for mishandled email.
  4. PA cannot be responsible for emails not being received due to technical issues with our hosting server.  If you do not receive a response in a timely fashion, you need to call the office.
  5. We reserve the right to copy emails sent to us to be used in the medical record.
  6. If you have questions about these policies, please call the office.

If you do not accept these terms, we will not be able to process your request online.

Please call the office at 816.561.8100 for further assistance.