Clone of Prescription Request Form

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: *

Month Day Year
Doctor: *

Kristeen Spratley MD John Burnside MD William Lee MD
Patient name: *

First Name Last Name
Birthdate *

Month Day Year
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.
Do You Have an Appointment Scheduled?

Month Day Year
Fields with an asterisk (*) are required.

Dr. Burnside, Dr. Spratley and Dr. Lee charge $10 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. If you require a WRITTEN PRESCRIPTION there will be a $10 charge for each prescription written.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.

If you absolutely need a guarantee that your prescription will be ready, you may consider the "Expedited prescription request", but it will be $25 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: *

Pick-up (Remember to allow 2 BUSINESS Days for pick up. Pick up Monday, Tuesday and Thursday only. ) Mail (Provide address under contact information and take into account mailing time.) Call In (Not available for stimulants.)
1st Prescription Request $10
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: *

Brand Generic
1st prescription milligrams: *
Directions on how you take the prescription i.e. 1 per day in the morning *
1st prescription quantity: *
2nd Prescription Request + $10
2. MEDICATION REQUESTED
2nd prescription type:

Brand Generic
2nd prescription milligrams:
Directions on how you take the prescription i.e. 1 per day in the morning
2nd prescription quantity:
3rd Prescription Request + $10
3. MEDICATION REQUESTED
3rd prescription type:

Brand Generic
3rd prescription milligrams:
Directions on how you take the prescription i.e. 1 per day in the morning
3rd prescription quantity:
Preferred Pharmacy name and address *
Pharmacy phone #: *
Contact Information
Full Name *

First Name Last Name
Address Changed?

Address Change
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
E-mail *
Contact relation: *
Contact phone #1: *

Area Code Phone Number
Contact phone #2:

Area Code Phone Number
Comments:
AFTER YOU HIT SEND, YOU WILL BE DIRECTED TO A PAYMENT PAGE.
Should be Empty:

Prescription Request Form

1st Prescription Request $10

2nd Prescription Request + $10

3rd Prescription Request + $10