1. What is your child's name (First and Last) ?   *   

2. What is your child's date of birth (mm/dd/yy) ?  * 

3. What medication are you requesting ?  *             

4. What strength (usually in milligrams) ?  *              

5. How many times a day is it taken ? *                    Once a day Twice daily Three times daily Four times daily Every Four Hours Every Six Hours Every Eight Hours Every Twelve Hours As Needed

6. Do you want:  *         Tablet/Capsule         Liquid         Chewable        

7. Do you want:  *         Generic         Brand

8. Do you want:  *         1-Month Supply         3-Month Supply

9 Handling:  *               Pick up         Mail Home         Mail to Pharmacy

10. If Mail to Pharmacy, which one (include location for chains) ?

11. Your name for contact purposes: *       

12. Telephone number to contact you: *   

13. E-Mail address for confirmation:

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