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. Do not use this form to request antibiotics or any other medication that your child does not take on a regular basis. Do not use this form to request a medication if you need a dosage change, please call our office (630-355-0003).

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:				Required
	Patient's name:				Required
	Patient's date of birth:		(mm/dd/yyyy)		Required
	Your e-mail address:				Required
	Phone number:				Required
	Pediatrician:		-select one - Dr. Gus Rousonelos Dr. Doris Nietert Dr. Erin Shanks Dr. Karolyn Law Dr. Ushma Patel		Required
	Name of medication:				Required
	Dosage and how often it is taken: (If no change, indicate same as usual)				Required
	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: