Prescription Request Form

Please tab through all of the required spaces to access the submit button at the bottom of the page.

Today's date:*

MonthDayYear

Doctor:*

Kristeen Spratley M.D.John Burnside M.D.William Lee M.D.

Patient name:*

First NameLast Name

Birthdate*

Date

Patient E-mail: (If minor: parent's email.)*

Failure to put a correct appointment date may delay your prescription request. Please leave this area blank if you do not have an appointment scheduled.

Fields with an asterisk (*) are required.

Prescription Fees are $15 per prescription written and $35 RUSH fee

Dr. Burnside, Dr. Spratley and Dr. Lee charge $15 for each stimulant prescription written between appointments. Stimulant medications include Adderall, Concerta, Ritalin, Vyvanse, etc.

Non - stimulant ( Zoloft, Prozac etc. ) please phone your pharmacy and have them FAX a prescription request for you to 210-496-2804 at no charge. Stimulant prescriptions will now be escribed. .If you need to check the status of your prescription please phone the office. Due to the number of prescriptions we process, we can not call to advise you of the status of the prescription. MOST of the time these are done same day but we do not make that guarentee.

If you absolutely need a guarantee that your prescription will be ready, you may consider the "Expedited prescription request", but it will be $35 per prescription in that instance. If your prescription is requested BEFORE NOON, it will be ready within 24hours. If after noon, it will not be ready until the NEXT BUSINESS DAY.

Delivery type:*

Please have the pharmacy fax over refill requests on Non-Stimulant's (EX: Depression meds) This will save you the prescription feeStimulants will be E-scribed. You must fill out this form and pay for the refill.

Please refer to your last prescription bottle or container to complete the information requested. Missing or incomplete information will delay your prescription.

1. MEDICATION REQUESTED*

1st prescription type:*

BrandGeneric

1st prescription milligrams:*

Directions on how you take the prescription i.e. 1 per day in the morning*

1st prescription quantity:*

2. MEDICATION REQUESTED

2nd prescription type:

BrandGeneric

2nd prescription milligrams:

Directions on how you take the prescription i.e. 1 per day in the morning

2nd prescription quantity:

3. MEDICATION REQUESTED

3rd prescription type:

BrandGeneric

3rd prescription milligrams:

Directions on how you take the prescription i.e. 1 per day in the morning

3rd prescription quantity:

Contact Information

Do You Have an Appointment Scheduled?

MonthDayYear

Preferred Pharmacy name and address*

Pharmacy phone #:*

Patient's Full Name*

First NameLast Name

Address Changed?

Address Change

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

E-mail*

Contact relation:*

Contact phone #1:*

Area CodePhone Number

Contact phone #2:

Area CodePhone Number

Comments:

AFTER YOU HIT SEND, YOU WILL BE DIRECTED TO A PAYMENT PAGE.

Prescription Request Form

We are aware of the ADHD medications shortages: Please call your pharmacy and check the availability of your prescription BEFORE REQUESTING YOUR PRESCRIPTION.

1st Prescription Request $15

2nd Prescription Request + $15

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3rd Prescription Request + $15