ADHD Shortage form

ADHD MEDICATION SHORTAGE
Please DO NOT have your Prescriber send a script to us unless we reach out to you to inform you, we have the medication and quantity in stock.
We are currently not able to fill any controlled substances including ADHD medications from any telehealth providers or from patients residing outside of 15 miles from Rock Ridge Pharmacy, NJ
Patient Status with Rock Ridge Pharmacy*

I am currently a Rock Ridge Pharmacy patient for prescriptionsI am currently a Rock Ridge Pharmacy patient for VaccinesI am new to Rock Ridge Pharmacy
Please select which applies to the patient?*

I live within 15 miles of the pharmacy and my prescriber for my ADHD medication is NOT a telehealth or online doctor.I do not live within 15 miles of Rock Ridge Pharmacy and/or my prescriber for my ADHD medication is a telehealth or online doctor. ***PLEASE DO NOT MOVE FORWARD AS WE WILL NOT BE ABLE TO FILL YOUR PRESCRIPTION***
Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Mailing Address*

Street Address

Street Address Line 2

CityState

Zip Code
Cell Phone Number*
Please list the name and city of your CURRENT PHARMACY*
Please list the name and city of the DOCTOR/PROVIDER who prescribes this medication for you. *
Select the name of the ADHD medication.*

GENERIC ADDERALLGENERIC ADDERALL XRGENERIC RITALINGENERIC RITALIN LAGENERIC FOCALINGENERIC FOCALIN XRGENERIC CONCERTA ERGENERIC METADATE CDGENERIC VYVANSEOTHER
What strength of this medication do you take?*
How many tablets or capsules do you receive each month for this prescription?*
Please list any other medications you may be taking.
Any other information you would like to add?
I confirm that I have a valid prescription for ADHD products NOT from a telehealth provider, reside in Bergen County and will not use this information for any other purpose. I understand and acknowledge that I will have my prescriber send a script to Rock Ridge Pharmacy only if I am informed to do so. I understand and acknowledge that this is only a request to be informed when Rock Ridge Pharmacy receives a medication and not a guarantee that I will receive it. I understand and acknowledge that Rock Ridge Pharmacy is trying their best to serve the community and this shortage; however, I will not call the pharmacy for updates as all updates will come via text from the pharmacy.

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ADHD MEDICATION SHORTAGE

Please DO NOT have your Prescriber send a script to us unless we reach out to you to inform you, we have the medication and quantity in stock.

We are currently not able to fill any controlled substances including ADHD medications from any telehealth providers or from patients residing outside of 15 miles from Rock Ridge Pharmacy, NJ