Medication Acknowledgment

PATIENT'S NAME*

First Last

MEDICATION(S)*

PATIENT'S DATE OF BIRTH*

DATE MEDICATION WILL BE COMPLETED*

FOLLOW-UP APPOINTMENT MUST BE NO LATER THAN*

CONTROLLED SUBSTANCES PRESCRIPTIONS ARE DIFFERENT

Stimulant Medication Acknowledgment*

I understand that stimulant medications (Ritalin, Adderall, Concerta, Vyvanse, etc.) are classified as controlled substances by the FDA and closely monitored by the Drug Enforcement Administration (DEA).
BY LAW, these medications:
- CANNOT be automatically refilled.
- CANNOT be phoned or faxed to a pharmacy.
- MUST be picked up in person, with ID verification.

IT'S A BIG DEAL IF THEY ARE LOST OR STOLEN

Lost or Stolen Prescription Acknowledgment*

I understand that if any of the issued prescriptions for stimulant medications are lost or stolen, a police report MUST be filed and a copy sent to our office BEFORE replacement prescription(s) are issued.

NOT ANYONE CAN PICK-UP THESE PRESCRIPTIONS

Parent Pick-up Acknowledgment*

I understand that the child's parent MUST pick-up these prescriptions. The parent will ALWAYS be required to show photo identification.

ALWAYS FILL THESE PRESCRIPTIONS IMMEDIATELY

ConsentStimulant Medication Expiration Acknowledgment*

I understand that stimulant medication prescriptions expire 21 days from the prescription date or the date printed in the Earliest Fill Date field, whichever date is later.

Expired prescriptions require us to reprint the prescription. You will be charged $25 for this service. There are NO exceptions.

If you receive a 90-day supply (three 30-day prescriptions), we strongly discourage you from giving all 3 to the pharmacy when you fill the first of the three prescriptions. If the pharmacy loses the prescription, we will have to reprint. You will be responsible and will result in a $25 reprint charge.

TEXAS CHARGES US FOR EACH PRESCRIPTION WE ISSUE

Reprint of Prescriptions Acknowledgment*

I understand that there is no charge for any prescriptions printed today. However, I agree to pay $25 for prescriptions that are reprinted for ANY reason (e.g., expiration, loss, theft).

$25 Charge for Printing a Prescription for a Partial Month's Supply*

I understand that the charge for today's prescriptions is included in the charge for today's visit.

I agree to pay $25 for extra prescriptions that are printed for ANY reason.

REPRINTING PRESCRIPTIONS ISN'T EASY OR QUICK

Prescription Reprint Acknowledgment*

I understand that it may take up to 72 hours to reprint a prescription.

IF WE REPRINT, YOU MUST RETURN THE ORIGINALS

Exchanging Prescriptions Acknowledgment*

I understand that prior to being issued a replacement prescription, I MUST exchange the original prescription for the replacement prescription.

WE MUST SEE YOUR CHILD AGAIN IN 3 MONTHS

Required Follow-up Acknowledgment*

I understand that my child will need to complete a follow-up appointment EVERY 3 MONTHS. The next appointment needs to occur at least 5 days BEFORE the completion of their medication supply.

Additional prescriptions WILL NOT be issued until the follow-up appointment is completed.

We AWLAYS recommend that you schedule your child's follow-up appointment BEFORE you leave today.

YOU MUST ACCOMPANY THE CHILD TO ALL VISITS

Parent Accompaniment Acknowledgment

I understand that a parent MUST accompany the child to ALL visits.

KEEPING THINGS ON-TIME

Arriving Late Acknowledgment*

I understand that my appointment WILL be rescheduled if I am more than 5 MINUTES late. There are NO exceptions.

To help you avoid having to reschedule due to a late arrival, we STRONGLY RECOMMEND arriving 10 minutes prior to your schedule appointment time.

FAILURE TO COMPLY

Parent Compliance Acknowledgment*

I understand that if I fail to comply with this agreement, the physician may discontinue medication and/or treatment.

Name of Parent or Legal Guardian*