ADHD Medication Shortage Form

Since October 2022, many ADHD medications—including Adderall, Concerta, and their generic equivalents—have been affected by a nationwide shortage.

We understand how stressful and frustrating this can be, especially for patients and families who rely on these medications and cannot safely stop them. Over the past few years, we’ve received a large number of calls from patients, parents, and providers all trying to navigate the same challenge.

As a local, independent pharmacy, our goal is always to support our community as best as we can. While we may not always have these medications available right away, we’ve created a process to help us stay organized and keep you informed when supply becomes available.

Through this form, we’ll ask a few questions about your medication, history, and basic information so our team can better understand how we may be able to help.

Important: Please do not have your prescriber send a prescription to us unless we’ve reached out to confirm that we have your medication and quantity available.
If a prescription is sent before that time, it will need to be cancelled unless you’ve been approved through this process and have received confirmation from our team.

Submitting this form allows us to notify you if and when we receive your medication—it does not guarantee availability.

Due to ongoing nationwide shortages of certain ADHD medications, locating available products may require additional pharmacist review, inventory verification, prescription coordination, and communication with prescribers and other pharmacies.

In certain situations, a $20 Medication Access Consultation Fee may apply when additional time and resources are required to evaluate available options, identify appropriate alternatives, or obtain medication through non-traditional supply channels due to limited availability or elevated acquisition costs.

If a fee may apply, we will notify you before proceeding.

At this time, we are unable to fill controlled substances, including ADHD medications, from telehealth providers or for patients located more than 20 miles from Skippack, PA.

**If you already get ADHD medication through Skippack Pharmacy, you do not need to fill out this form again...we just need this form filled out once & we have you covered once you are in**

Patient Status with Skippack Pharmacy

Please select which applies to the patient.

Who is filling out this form?

Patient's Name

First NameLast Name

Date of Birth

MonthDayYear

Patient Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Cell Phone Number

Area CodePhone Number

Email

Please double check and ensure this is accurate

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 you take ***we do not have access to any brand name ADHD medications, if filling this out for a brand name, please do not move fwd***?

What strength of this medication do you take?

How many tablets or capsules do you receive each month for this prescription?

Do you take any other ADHD product(s)?

Which other ADHD medication do you take?

What strength of this medication do you take?

How many tablets or capsules do you receive each month for this prescription?

Do you take any other ADHD product(s)?

If additional pharmacist review, coordination, or special procurement is required due to ADHD medication shortages, would you be willing to pay a $20 Medication Access Consultation Fee?

Which other ADHD medication do you take?

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?

Please upload a copy of your insurance card.

Please input the numbers/letters from your Prescription Insurance card. You are looking at your prescription card if it has the letters RX on it otherwise, you are likely looking at your medical card. If you don't have insurance just put no insurance.

I confirm that I have a valid prescription for ADHD products NOT from a telehealth provider, reside within 20 miles of Skippack Pharmacy and will not use this information for any other purpose. I understand and acknowledge that I will have my prescriber send a script to Skippack Pharmacy only if I am informed to do so. I understand and acknowledge that this is only a request to be informed when Skippack Pharmacy receives a medication and not a guarantee that I will receive it. I understand and acknowledge that Skippack Pharmacy is trying their best to serve the community and this shortage; however, I will not call or email the pharmacy for updates as all updates will come via email/text from the pharmacy.