Prescription Refill Request
If you already had a presription filled, please call your pharmacy and have them request
the refill.
ADD/ADHD Prescription Refills
Please Allow 24 to 48 hours for processing. If youhave not heard back from us within this
time, please call to check if the prescription is ready to be picked up.
Patient
First Name
Last Name
Birthdate
January
February
March
April
May
June
July
August
September
October
November
December
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Fairway Pediatrician
Person Making Request
First Name
Last Name
Relation to Patient
Father
Mother
Relative
Other
Phone Number
Home
Cell
Work
Phone Number
Home
Cell
Work
Prescription Requesting
Comments/Suggestions
Please do not make another request if you have left one on the office voice mail.