*Who is your child's primary physician?
   Please select Dr. Kordisch Dr. Thompson Dr. Wallace Dr. Landry Dr. McCanless Dr. Karriker Dr. Maust Dr. Decker Dr. Drez Dr. Karpovs Dr. Sumrall Beth Savoie RN CPNP Misty Bowman RN CPNP

*Patient's Name:
  
   (first and last name)

*Birth Date:      
  
  (format: 00-00-00)

*Home telephone:
  
  (format: 000-000-0000)

*Other telephone number:
  
    (format: 000-000-0000) 

*Email address:  
  

*Confirm email address:
  

*What is the name of the medication to be refilled?
   Please select Adderall Adderall XR Concerta Dexedrine Dexedrine spansule Focalin Focalin X12 Metadate Metadate CD Metadate ER Methylphenidate Methylphenidate ER Ritalin Ritalin LA Ritalin SR Stratterra Other
  If "other" is selected, enter the name of medication:
  

*What is the strength (mg.) of the medication?
   Please select 2.5 mg 5 mg 10 mg 15 mg 20 mg 25 mg 30 mg 40 mg 54 mg 60 mg other
   If "other" is selected, enter the strength (mg).
  

* How much and how often does the child take the
   medication?
   Please select 1 tablet every morning 2 tablets every morning 1 tablet every morning and at lunch 1 tablet in the morning and 1/2 at lunch 2 tablets in the morning and 1 at lunch 2 tablets in the morning and 2 at lunch Other
   If "other" is selected, enter the directions on presciption:
  

*What is the condition or diagnosis for which child is
   prescribed this medication?   
    Please select ADHD ADD Seizure disorder Other
   If "other" is selected, enter the diagnosis:
  

*Where do you want the written prescription to be sent?
   Please select Patient Services for pick up Sulphur office for pick up South Lake Charles office for pick up Moss Bluff office for pick up Children's Pharmacy to be filled

  Comments: