Prescription Refill Request Form

Prescription Refills
Prescription refills other than ADHD meds and other controlled medications requested before 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 the pharmacy 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
Medications such as Adderall, Vyvanse, Methylphenidate, and Ritalin are controlled medications and must be refilled monthly. ADD/ADHD medications are sent electronically to the pharmacy listed in your child’s chart.

Allow up to 7 days for a refill to be processed due to the chart review done by the primary physician. Required yearly checkups and “medication follow-up appointments” directed by your primary provider must be current to refill ADD/ADHD medications.

Failure to schedule and keep recommended visits will result in no refills prescribed until the patient is seen in the office.

Patient Information

Contact Information

Patient Name

Give first and last names

Primary Phone

Use the format 317-555-1212

Date of Birth

Use the format MM/DD/YYYY

Alternate Phone

Use the format 317-555-1212

Parent / Guardian Name

Give first and last names

Primary Care Physician

Pharmacy Name

Pharmacy Phone

Pharmacy Address

Prescription Details

Medication Requested

Dosage

Days Supply

How often is medication taken?

Northpoint Pediatrics

Prescription Refill Request Form

Locations

Community Health Pavilion on 146th

Community Hospital North Campus