ADD Medication Refill

Name

Date of Birth

Email

Check Appropriate

Refill Adderall
Refill Vyvanse
Refill Mydayis
Refill Focalin
Refill Concerta
Refill Other

if other, please specify

Quantity

Send one 90 day prescription
Send 3 x 30 day prescription
Send another configuration

If different configuration, please specify

Pharmacy

My regular pharmacy
I need to change my pharmacy

Pharmacy location

Please attest to the following

Please attest to the following
I've been seen in person or virtually in the past 6 months
I agree to a $10 charge to the credit card on file

Any other comments or information

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