Prescription Request Form

Terms of use

*By agreeing to the terms of our online requests page, you will enter a secure area of our site. Pediatric Associates of Norwood and Franklin,P.C. will not be held responsible in the event that your electronic message is not transmitted due to technical problems related to this site or to the hosting server.

All personally identifying information is encrypted and your message will not be internally or externally forwarded to third parties. The information will be solely used by Pediatric Associates of Norwood and Franklin, P.C. As these requests are sent over the Internet we cannot assure complete confidentiality. If you are concerned about the confidentiality of your request, please call the office to place your request.

Please use this service for non-emergent/urgent requests only. All prescription refill requests are reviewed by a Physician or Nurse Practitioner who will determine if your child has been seen within an appropriate time frame and if the refill is medically appropriate.

Our intent is to process your request in 48-72 hours depending on when they request is received. Online Requests will be monitored from 9:00 A.M.-4:00 P.M. Monday-Friday (excluding holidays). Please, allow up to 72 hours for your Refill Request to be processed or responded to.

If you are requesting a refill of a controlled substance, you must pick up the prescription from our office as we cannot send them electronically to the pharmacy. Otherwise, your prescription will be sent to the pharmacy indicated on your request.

If you do no accept the terms of this disclaimer, you will not be able to process your request online.

I agree to terms of use

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Fields indicated with (*) are required.

The online prescription refill request form is for prescriptions of a chronic nature (i.e. allergy medications, asthma medications, ADHD medications and long term therapeutic agents) Please allow ample time for your request to be processed. If you have only one pill left and need a prescription refilled ASAP call the office directly. Your request must be reviewed by a Physician or Nurse Practitioner and in some cases may only be renewed by your Primary Care Provider.

Complete the secure form below and press submit. If there is a problem with your prescription refill request or we require additional information from you, we will contact you by phone.

THANK YOU for this opportunity to serve you.

Parent / Guardian Info*

First name

Last name

Contact phone #

Phone

Patients Name*

First Name

Last Name

Patients Date of Birth

Month

Day

Year

My Provider is

Medication Allergies

Office Location

Medication

Strength

Amount Per Dose

Frequency

Pharmacy Info*

Name of Pharmacy

Street Address

City

State

Zip Code

Comments or concerns about your child's medication

I understand that the information submitted may include personal health information and consent to its secure storage and use.

115 Norwood Park South Suite 110, Norwood, MA 02062

781-769-4090 or 508-528-5404

Prescription Request Form