PEDIATRIC ASSOCIATES, INC.
REQUEST FOR ADD/ADHD REFILL
EMAIL: MAIL@PAIKIDS.COM
FAX TO : (260)436-2703
DATE:
_____________________
Patient name: ___________________________________
Patient Date of Birth: ______________________________
Parents Names: ___________________________________
Contact Number: ___________________________________
Alternate Number: __________________________________
Name of prescription being refilled? _______________________
Current Dose _________________
How is patient doing? ___________________________________
Primary physician @ PAI _________________________
Date of last check up? _____________________________
Date of next check up? _____________________________
Brand Name or Generic? ____________________________
To be picked up by: _____________________________________
(Note: Do not pick prescription up until notified that it has been written.)
___________________________________
Parent/Guardian signature
________________
Date
For office use only:
Request completed by: ______________