Change to Prescription
PLEASE NOTE:
- 48 hrs (2 business days) notice is required for all Rx change requests - Medication checks (office visits) are required every three months for stimulant medications. - An * denotes a required field
*Patient's name
*Patient's DOB
*Phone #1
Phone #2
Person making request
Phone (if different)
*Current Rx name (be specific)
*Current Rx strength (mg)
*Current Quantity
*Current instructions or SIG
*Requested Change (be specific)