Pediatrics Associates of Norwood & Franklin

Patient Forms

Request a prescription

Prescription Refill requests online is a new service from PANF in an effort to reduce your need to make a telephone call into our busy office telephones.

All prescription refill requests are reviewed by your physician, so please complete the form as indicated for one child only, additional requests for another child must be completed with another online request. Only your physician will determine if you have been seen within an appropriate time and your refill is medically appropriate or whether your child will need to be seen by the physician.

Please note:

This is the internet. We cannot assure your confidentiality. If you are concerned about the confidentiality of a request, please use the telephone to request a refill.
Please use this service for non-emergent/urgent requests only. Normally requests will be filled or responded to within 24 hours.
We can only respond to this service during normal working hours (8:00 am to 5:00), Monday through Friday.
Some prescriptions must be written and are not allowed by law to be called into a pharmacy. These must be picked up and taken to a pharmacy on a printed prescription.

THANK YOU for this opportunity to serve you.

Parent/Guardian Information

First Name *

Last Name *

Home Phone *

E-mail Address *

Street

Apartment

City

State

Zip Code

Patient Information

Patient First Name *

Patient Last Name *

Patient's Date of Birth *

Current Weight

Allergic to any Medicines? *

If yes, please specify:

Which office did you visit? *

My physician is *

Medication Requested for Refill

Medication Name *

Dosage (i.e. # of tabs/tsp of med/ how often) *

ADD/ADHD Medications: How is the patient doing on current dose?

Check here if you wish to pick up the prescription in our office

Pharmacy *

Pharmacy Street

Pharmacy City/Town

Pharmacy Phone *

Comments