Medication Request
This form is for requesting refills or new prescriptions on medication you are already on, only. If you are looking to change your medication, please contact the office directly, or leave a message for the doctor's clinical voicemail by pressing 2 (two) at the recorded greeting.

If this is a request for an ADD/ADHD controlled medication script, please call to confirm the prescription before coming to pick it up.

There is a $15 dollar fee for scripts written other than at your appointments, unless otherwise arranged with the office.
Full Name *
Date of Birth *
MM/DD/YYYY
Phone Number *
Remember extension and best hours, if applicable.
When was your last appointment?
Regardless of the number of scripts written in the intervening time, failure to make regular appointments will keep the doctor from writing prescriptions.
Medication Requested *
Medication, strength, and dosage; IE Adderall XR 20mg, one in the morning and one in the afternoon.
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This form was created inside of R. Ellen Allbritton, M.D..