Patient Information




Date of Birth:

Guardian Information




* Telephone number(s) you can be reached at during the day.:




Prescription Information

NOTE: All Class II medications (Ritalin, Adderall, Concerta, Metadate,etc) must be picked up at the office:


If Send to Pharmacy




Electronic Signature

By entering my name below, I understand that I am providing an electronic signature which will serve as an affirmation that I'm the parent/legal guardian of the patient entered above.: