Patient Information

   

   
   

   
   

   
Date of Birth:
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Guardian Information

   

   
   

   
   

   
* Telephone number(s) you can be reached at during the day.:

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Prescription Information

NOTE: All Class II medications (Ritalin, Adderall, Concerta, Metadate,etc) must be picked up at the office:


 
 

If Send to Pharmacy

 

 
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Authorization




Electronic Signature

By entering my name below, I understand that I am providing an electronic signature which will serve as an affirmation that I'm the parent/legal guardian of the patient entered above.: