Please do not use this form

> to request antibiotics or any other medication that your child does not take on a regular basis.

> to request a medication if you need a dosage change, please call our office (630-355-0003).

> if you need the medication immediately.
REFILL REQUEST
Use this form to request a medication refill. Please only use this to request a medication that your child takes often and that we have prescribed in the past, such as daily asthma medication or daily medication for ADHD.
Please allow us 2 business days to prepare your refill, so do not use this form if you need the medication immediately - instead, just call our office (630-355-0003). When you submit the form, you will see a confirmation page indicating what you have requested. If any information is incorrect, then come back to this form and try again. When your prescription either has been called to the pharmacy or has been written and is ready for pickup you will receive another e-mail.

Before using any of the e-mail functions, please read our E-mail Disclaimer.

Your name:
Patient's name:
Patient's date of birth:
Your e-mail address:
Phone number:
Pediatrician:
Name of medication:
Dosage and how often it is taken:
(If no change, indicate same as usual)
Fill in the following two fields if you would like the prescription called to a pharmacy: (do not use this for ADHD medications other than Strattera)
Name of pharmacy:
Phone number of pharmacy: