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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 checkups and follow up appointments 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 checkups and “medication follow up appointments” directed by your primary provider must be current in order to refill ADD/ADHD medications.