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ADHD Transfer/Change Request
The nationwide shortage has made access to ADHD Medications frustrating for everyone. Please fill out the form below so we can expedite the process of transferring your prescription to a pharmacy that has it in stock. Prescriptions will be sent within 24 hours.
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First and Last Name
*
Your answer
Date of Birth
*
Your answer
Phone Number
*
Your answer
Name of New Pharmacy
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Your answer
Complete Pharmacy Address
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Your answer
Have you verified they have your dosage in stock? (Only one transfer allowed per month, please verify)
*
Yes
No
Required
Does the strength/dosage need to be adjusted for the prescription to be filled? If so, what changes need to be made? (If doesn't not equal current prescription, appointment may be needed to adjust.)
*
Your answer
Would you like to speak with someone about an alternative medication?
*
Yes
No
Required
Additional Comments
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