Request a Refill

Catalina Pediatrics Web Site

Use this form to request a medication refill. Please only use this to request a medication that your child takes often and that we have prescribed in the past, such as daily asthma medication or daily medication for ADHD. Do not use this form to request antibiotics or any other medication that your child does not take on a regular basis. Please allow us 2 business days to prepare your refill, so do not use this form if you need the medication immediately - instead, just call our office (323-3099) or the pharmacy. If you are requesting a dosage change, we will probably have to call you to discuss the reason for the change, so make sure your contact information is accurate on this form. When you submit the form, you will see a confirmation page indicating what you have requested. If any information is incorrect, then come back to this form and try again. When your prescription either has been called to the pharmacy or has been written and is ready for pickup you will receive another email.

Before using any of the email functions, please read our Email Disclaimer.

Your Name:

Patient's Name:

Patient's Date of Birth:

Your E-mail Address:

Phone Number (indicate the phone number or numbers at which you can most easily be reached):

Who is your pediatrician?

What is the name of the medication?

What is the dosage and how often is it taken (if no changes, you can indicate "same as usual"?

Fill in the following two fields if you would like the prescription called to a pharmacy: (do not use this for ADHD medications other than Strattera)

What is the name of the pharmacy?

What is the phone # of the pharmacy?

Any special requests or other information?

Date this page was last changed: 10/28/2007

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