ADHD Medication Refill Request ADHD Medication Refill Request Patient's Name* Patient's Date of Birth* Phone* Email* Clinic Location*Odessa 5th StOdessa University BlvdMidlandCorpus Christi Medication*Adderall XRAdderall Dextroamph/Amphetamine Dextroamph/Amphetamine ERAtomoxetineAzstarisConcertaClonidineDaytrana PatchDexmethylphenidate ERDexmethylphenidateFocalin XRFocalinGuanfacineIntunivJornay PMLisdexamfetamineMethylphenidateMethylphenidate ERQelbreeQuillichewQuillivant XRRitalin LARitalinStratteraVyvanseOther (use comment section) Pharmacy (only if different from the previous pharmacy) Comment (optional)SubmitReset
