Requests and Forms — ADHD Boston

Online Forms for Current Patients

Refill Request

Prescription Refill

Name

First Name

Last Name

Email Address

Medication(s) and mg (dose)

Pharmacy store name, address, zip code

Message

Appointment Status: Please Check One

I have scheduled a follow up appointment

I have not scheduled yet, but had an appointment within the past 4 weeks

I have not scheduled a follow up appointment, and I understand my request may be delayed until I have scheduled

Schedule Online

Click to Schedule

Invoice Request

Medication P.A. Request

Invoice Request

Client Name

First Name

Last Name

Email Address

Dates of Service

Message

Prior Authorization Request

Client Name

First Name

Last Name

Email Address

Medication needing authorization

Home address

Address on file with Insurance

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Release of information

By checking this box, I authorize release of my medical records for the purpose of insurance authorization

Authorization Acceptance