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• You are being offered between-visit s3mulant refills as an alterna3ve to a7ending monthly sessions with your provider for your refills. If you prefer the la7er op3on, please inform us and do not submit this form.
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• Refills are processed Tuesday – Friday of each week. • When your request is processed, $42 will be charged to your credit card on file.
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• Please allow up to 4 business days for processing, although most requests are processed within 2 business days.
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• Please do not request a refill just before an appointment, as refills are provided at each appointment. If you need a refill up to 3 weeks before your appointment date, contact us
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We’ll do our best to reschedule an earlier appointment for you (this will save you an unnecessary refill fee).
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Have you had an appointment with your provider in the last 90 days or within the 6me period recommended by your provider?For safety and compliance, we require that you see your medical provider at least every 90 days for ADHD
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Which ADHD medication refills are you requesting?
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Other Medication:
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Have you begun taking any medications or supplements you have yet to advise your provider about? Your provider must be aware of all supplements and medications you are taking.
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Has your pharmacy informa6on changed since your last refill? Remember that you may change pharmacies no more frequently than every six months because we haven’t sufficient staffing to accommodate more frequent changes.
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New Pharmacy
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OPTIONAL: If you have additional information you believe is necessary for us to process your request, include it here; however, please bear in mind that this can cause a processing delay of up to five business days:
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I understand that payment of the abovementioned fees does not guarantee that my refill request will be granted.
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There are no refunds or credits for refill request fees. There are no exceptions to this policy, including denied refill requests.
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I understand that my request will be denied if I’m overdue for a drug screen.
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I understand my request will be denied if I have an outstanding or overdue balance.
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I understand that my request may be denied if staff or providers have any reason to believe that the requested refill is not in my best interest.
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I agree to pick up the refill no sooner than 30 days a`er the date that the previous prescrip6on was picked up, even if my pharmacy allows me to do otherwise or agrees to release my prescrip6on earlier.
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I understand that if my refill is denied, I’ll need to re-submit the request (and pay the associated fee) once the reason for the denial has been resolved.
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For all questions regarding refill requests, you'll need to communicate directly with your pharmacy
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