Prescription Refill Request Form

Patient Information



Give first and last names



Use the format MM/DD/YYYY



Give first and last names



For directions to each of our locations, please see our Location pages.


Contact Information



Use the format 317-555-1212



Use the format 317-555-1212



Yes No

Prescription Details






Limit: 1,500 Characters


Call in to Pharmacy
Pick up in Person
Mail to my House

Call to Pharmacy

Call this prescription in to my pharmacy





(Use the format 317-555-1212)

Note: Some medications, including stimulants used to treat ADHD, can not be called in to a pharmacy.

Pick up in Person

I will pick my prescription up from :

Mail to Home

Mail this prescription to my home address:






Note: This address will be compared with address on file for the patient.

Please enter in the word you see

   




Notes About this Form

Prescription Refills
Prescription refills [other than ADHD meds and other controlled substances] requested prior to 1:30 pm will be processed by the end of the business day. Refill requests received after 1:30 pm will be processed by the end of the next business day and sent electronically to your pharmacy. (Pharmacy information that is listed in your child’s chart) Yearly check-ups and follow-ups by a Northpoint provider are required to continue to refill medications.

 ADHD Medication Refills
Controlled medications such as ADD meds (Adderall, Vyvanse, Methylphenidate, Ritalin, etc.) must be refilled monthly. ADD/ADHD medications can soon be sent electronically to the pharmacy. (Pharmacy information that is listed in your child’s chart) The processing time for your refill may take up to 7 days due to chart review by the primary physician. Required yearly check-ups and “medication follow-ups” directed by your primary provider must be current in order to refill ADD/ADHD medications.