Prescription Request

Prescription Request

Patients must be seen once every 90 days in order to request a medication renewal.
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Who is your prescriber?
Please select the correct prescriber so your request goes to an actual person!
Prescriber Mojo Email
example@example.com
Prescriber Ann Arbor Psych Email
example@example.com
What is the soonest you will run out of any of your meds?
Are any of these medications going to a different pharmacy than usual?
Please read and check off all to progress.
Do you have a follow up appointment? If so, let us know when. A follow up appointment is something we need to send meds, so if you do not have a follow up appointment already, use the link after this question to make one and let us know what date you made it for.
We cannot renew medications without a follow up appointment. If you don't have one, click the link below and select your prescriber.
Schedule with prescribers: https://annarborpsych.com/prescribers-2/
- 1st Medication
- Medication 1
  As written on bottle
- If this is a stimulant (Adderall, Ritalin, Concerta, Vyvanse, Methylpendidate, Dextroamphetamine): Please speak with pharmacy before requesting and note what they said below. We ask you call them because 90% of the time the script is already waiting at the pharmacy. Because legally "renewals" are not allowed for stimulants, you will NOT get a notice from pharmacy to pick up the next script the way you do with all other medications. Instead, separate 30 day scripts were sent for you and 90% likelihood is that a 30 day script is waiting for you at the pharmacy.
  What did the pharmacy say? Please write this above. We respectfully require that you speak to pharmacist or pharmacy tech before submitting for medication renewal of a stimulant.
- Medication 1: How many days (30 vs 90) does this refill need to be in order to last till your next scheduled appointment? If this was a 90 day script that the pharmacy, for whatever reason, only sent 30 days of, let us know here.
- Dose from bottle
  This is necessary to avoid medication errors
- How many pills per day does your prescription say to take, and what is the timing? Also, how many times per month on average is it taken?
- Have you run out of this medication? If so how long has it been since you took it regularly?
  If you have run out of Lamictal, please indicate this as it needs to be re-titrated in order to be safe. Many medications need doses worked back up slowly in order to be taken safely.
- When will you run out of this medication?
- We typically send enough medication to get you through till the next appointment. Do you know what happened that you had to call to get this script sent?
  
  Type any other answers here
- Which pharmacy is this script going to? (Name of pharmacy, city, street)
- If you are moving the script what was the original pharmacy? It is important for us to cancel the medication at the original pharmacy to avoid your Michigan Automated Prescription System appearing irregular
- 2nd Medication
- Medication 2
  As written on bottle
- If this is a stimulant (Adderall, Ritalin, Concerta, Vyvanse, Methylpendidate, Dextroamphetamine): Please speak with pharmacy before requesting and note what they said below. We ask you call them because 90% of the time the script is already waiting at the pharmacy. Because legally "renewals" are not allowed for stimulants, you will NOT get a notice from pharmacy to pick up the next script the way you do with all other medications. Instead, separate 30 day scripts were sent for you and 90% likelihood is that a 30 day script is waiting for you at the pharmacy.
  What did the pharmacy say? Please write this above. We respectfully require that you speak to pharmacist or pharmacy tech before submitting for medication renewal of a stimulant.
- Medication 2: How many days (30 vs 90) does this refill (medication 2) need to be in order to last till your next scheduled appointment? If this was a 90 day script that the pharmacy, for whatever reason, only sent 30 days of, let us know here.
- Dose from bottle
  This is necessary to avoid medication errors
- How many pills per day does your prescription say to take, and what is the timing? Also, how many times per month on average is it taken?
- Have you run out of this medication? If so how long has it been since you took it regularly?
  If you have run out of Lamictal, please indicate this as it needs to be re-titrated in order to be safe. Many medications need doses worked back up slowly in order to be taken safely.
- When will you run out of this medication?
- We typically send enough medication to get you through till the next appointment. Do you know what happened that you had to call to get this script sent?
  
  Type any other answers here
- IMPORTANT!!! Which pharmacy is this script going to? (Name of pharmacy, city, street)
  If we have never prescribed to this pharmacy for you, we need the full street address and city in order to disambiguate.
- If you are moving the script what was the original pharmacy? It is important for us to cancel the medication at the original pharmacy to avoid your Michigan Automated Prescription System appearing irregular
- 3rd Medication
- Medication 3
  As written on bottle
- If this is a stimulant (Adderall, Ritalin, Concerta, Vyvanse, Methylpendidate, Dextroamphetamine): Please speak with pharmacy before requesting and note what they said below. We ask you call them because 90% of the time the script is already waiting at the pharmacy. Because legally "renewals" are not allowed for stimulants, you will NOT get a notice from pharmacy to pick up the next script the way you do with all other medications. Instead, separate 30 day scripts were sent for you and 90% likelihood is that a 30 day script is waiting for you at the pharmacy.
  What did the pharmacy say? Please write this above. We respectfully require that you speak to pharmacist or pharmacy tech before submitting for medication renewal of a stimulant.
- Medication 3: How many days (30 vs 90) does this refill (medication 3) need to be in order to last till your next scheduled appointment? If this was a 90 day script that the pharmacy, for whatever reason, only sent 30 days of, let us know here.
- Dose from bottle
  This is necessary to avoid medication errors
- How many pills per day does your prescription say to take, and what is the timing? Also, how many times per month on average is it taken?
- Have you run out of this medication? If so how long has it been since you took it regularly?
  If you have run out of Lamictal, please indicate this as it needs to be re-titrated in order to be safe. Many medications need doses worked back up slowly in order to be taken safely.
- When will you run out of this medication?
- We typically send enough medication to get you through till the next appointment. Do you know what happened that you had to call to get this script sent?
  
  Type any other answers here
- Which pharmacy is this script going to? (Name of pharmacy, city, street)
- If you are moving the script what was the original pharmacy? It is important for us to cancel the medication at the original pharmacy to avoid your Michigan Automated Prescription System appearing irregular
- 4th Medication (Phew! Almost done!)
- Medication 4
  As written on bottle
- If this is a stimulant (Adderall, Ritalin, Concerta, Vyvanse, Methylpendidate, Dextroamphetamine): Please speak with pharmacy before requesting and note what they said below. We ask you call them because 90% of the time the script is already waiting at the pharmacy. Because legally "renewals" are not allowed for stimulants, you will NOT get a notice from pharmacy to pick up the next script the way you do with all other medications. Instead, separate 30 day scripts were sent for you and 90% likelihood is that a 30 day script is waiting for you at the pharmacy.
  What did the pharmacy say? Please write this above. We respectfully require that you speak to pharmacist or pharmacy tech before submitting for medication renewal of a stimulant.
- Medication 4: How many days (30 vs 90) does this refill (medication 4) need to be in order to last till your next scheduled appointment? If this was a 90 day script that the pharmacy, for whatever reason, only sent 30 days of, let us know here.
- Dose from bottle
  This is necessary to avoid medication errors
- How many pills per day does your prescription say to take, and what is the timing? Also, how many times per month on average is it taken?
- Have you run out of this medication? If so how long has it been since you took it regularly?
  If you have run out of Lamictal, please indicate this as it needs to be re-titrated in order to be safe. Many medications need doses worked back up slowly in order to be taken safely.
- When will you run out of this medication?
- We typically send enough medication to get you through till the next appointment. Do you know what happened that you had to call to get this script sent?
  
  Type any other answers here
- Which pharmacy is this script going to? (Name of pharmacy, city, street)
- If you are moving the script what was the original pharmacy? It is important for us to cancel the medication at the original pharmacy to avoid your Michigan Automated Prescription System appearing irregular
- Please check with your pharmacy in 24 business hours if they do not reach out to you regarding receiving the prescription.
- Should be Empty: