http://www.jotform.com/answers/305706-The-word-prescription-on-one-of-our-forms-is-being-changed-to-preion-

Today's date:*

MonthDayYear

Doctor:*

John C. BurnsideKristeen R. Spratley

Patient name:*

First NameLast Name

It is the patient’s responsibility to check the status of prescriptions. We do not call and inform you that your prescriptions is ready.

Stimulant prescriptions must be filled within 21 days. All expired prescriptions must be returned before new prescriptions will be issued. There is a $10.00 fee to re-write expired Prescriptions. Stimulant Prescriptions must be picked up or mailed. They cannot be called in.

Fields with an asterisk (*) are required.

Attention:

Beginning January 1^st, 2014, Dr. Burnside and Dr. Spratley will charge $10 for each stimulant prescriptions written between appointments. Stimulant medications included Adderall, Concerta, Ritalin, Vyvanse, etc.

Allow 48 business hours for the prescriptions to be written. Remember you have 21 days from the earliest fill date (bottom left corner) to fill a stimulant prescription. Plan ahead and order your prescriptionss 7-10 days early, especially, if you are having them mailed.

If you cannot wait 48 hours and need a prescription within 24 hours, the charge will be $25 per prescriptions.

Prescriptions can no longer be requested by phone.

If the medication is not a stimulant / controlled product, have your pharmacy fax a prescriptions refill request to our office (210-496-2804).

Please allow 48 business hours for refills. Prescriptions requested on Thursday after 12:00pm may not be ready until Tuesday.

1st Prescription Request

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

1st prescription name:*

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:*

1st prescription delivery type:*

Pick-up (Remember to allow 2 BUSINESS Days for pick up)Mail (Provide address under contact information.)Call In (Not available for stimulants.)

2nd Prescription Request

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

2nd prescription name:

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:

2nd prescription delivery type

Pick-up (Remember to allow 2 BUSINESS Days for pick up)Mail (Provide address under contact information.)Call In (Not available for stimulants.)

3rd Prescription Request

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

3rd prescription name:

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:

3rd prescription delivery type

Pick-up (Remember to allow 2 BUSINESS Days for pick up)Mail (Provide address under contact information.)Call In (Not available for stimulants.)

Pharmacy name:

Pharmacy phone #:

Contact Information

Full Name*

First NameLast Name

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:

Prescription Request Form