PrimeCare Pediatrics

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Prescription Refills

Please complete the fields below and click submit. If there is a problem with your prescription refill request or we require more information from you, we will contact you by phone.

Due to DEA regulations, prescriptions and refills for certain regulated medications, such as Adderall, Concerta, Dexedrine, Metadate, Focalin, and Ritalin can ONLY be picked up in person at our office.


	Patient First Name*:
	Patient Middle Initial:
	Patient Last Name*:
	Patient Birth Date*:	Month: Day: Year:
	Parent/Guardian First Name*:
	Parent/Guardian Middle Initial:
	Patent/Guardian Last Name*:
	Home Phone:
	Work Phone:
	Mobile Phone:
	Contact At:	Home Work Mobile
	Medication Name*:
	Medication Strength*:	mg ml
	Type*:
	Dosage*:
	Frequency*:
	Pharmacy Name:
	Pharmacy Phone:
	Would You Prefer:	Phone-In Pick-Up
	Comments:
	* Denotes required fields

(c) 2009 PrimeCare Pediatrics, PC - 15A Baynard Park - Newnan, GA 30265
Phone (770) 251-5253 - Fax (770) 251-5254
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