School Medication Request Form

Please review the following:

Electronic School Forms through the Portal:

• All school forms processed through the patient portal (My Chart Plus) will continue to be free of charge.
• Please expect no more than 14 days turn around from the time of the request for electronic forms processed through the portal.
• You MUST have portal access activated to receive forms.
• If you need an activation code, please note this request and look for the activation code in your email.
• All patients 13 – 17.99 years of age must activate their own account as proxy accounts for this age cannot receive school forms.

Electronic School Forms Printed:

• Any electronic school forms that are printed for mailing to the home are subject to a $5 per form fee.
• We are not allowing for pick up of forms in our office due to COVID-19. Forms will not be faxed or emailed.
• Please expect up to 7 additional days (21 days total) to receive mailed school forms.

Specialty School Forms:

• Any special forms that are school or daycare specific to be completed by hand may take up to 4 weeks to process.
• Please include a self-addressed stamped envelope.
• These will be mailed home and are subject to a $15 per form fee.

We are not allowing for pick up or drop off of forms in our office due to COVID-19. Forms will not be faxed or emailed

While every effort is made to complete the forms in a timely fashion, please be aware that at certain times of year we may receive dozens of school forms daily. Parents/Guardians are strongly advised not to wait until the last moment to request school medication forms for their children.

MEDICATION REFILL REQUEST

PREFERRED PHARMACY IF REQUESTING REFILLS