"*" indicates required fields Choose appointment type* NEW Patient RETURNING Patient This field is hidden when viewing the formYour State*ARIZONACOLORADOCONNECTICUTDISTRICT OF COLUMBIAHAWAIIIDAHOILLINOISIOWAMAINEMARYLANDMINNESOTAMONTANANEBRASKANEVADANEW MEXICONORTH DAKOTAOREGONSOUTH DAKOTAVERMONTWASHINGTONWe are only licensed in these statesThis field is hidden when viewing the formAre you seeking treatment for ADHD?* Yes No This field is hidden when viewing the formDOSE LIMITS*We do not prescribe above FDA-indicated doses. No more than: Adderall 40mg/day Vyvanse 70mg/day Ritalin (Methylphenidate) 60mg/day I understand & agree to this policyThis field is hidden when viewing the formPAYMENT DOES NOT GUARANTEE MEDICATION*We assess you first. We provide alternatives if we think that medication is not appropriate. We may need further medical or lab testing before issuing a prescription. I understand & agree to this policyThis field is hidden when viewing the form30 DAYS FROM YOUR LAST PRESCRIPTION*We do not fill medications until 30 days have passed from the last controlled medication filled per the national prescription drug monitoring report. I understand & agree to this policy
