This service is for patients who need to refill medications such as those used in the treatment of ADD, ADHD, seizure disorders or other chronic conditions.

Terms of Use

By submitting this form, you are agreeing to the terms of our Online Prescription Renewal Request you will enter a secure area of our site. The Children’s Clinic will not be held responsible in the event your electronic message is not transmitted due to technical problems related to this site or to the hosting server. All personal identifying information is encrypted and your message will not be internally or externally forwarded to other third parties. The information will solely be used by the Children’s Clinic.

Your request will be processed within 24 hours, during normal business hours, Monday – Friday, 8:00 am – 5:00 pm, excluding holidays. Please be aware that depending on the availability of your physician and the location you choose to send the prescription, it may take longer. If you need the refill immediately, please call us directly.

To use this service, your child must be a patient of our practice. He/she should have been seen within the last twelve months for a physical. For some conditions (e.g. diabetes, asthma, reflux), your physician may recommend an appointment before refilling the medications. For controlled substances (e.g. attention deficit disorder medications), a recent appointment is required.

If you do not accept the terms of this disclaimer, we will not be able to process your request on-line.

Please request refills at least one week before your child will be out of medicine. Your child’s physician is the only one who will write the prescription and may not be in the office the day of your request.

CCSWLA – Prescription Request

I Agree to Terms(Required)
Patient Name(Required)
MM slash DD slash YYYY
What is the name of the medication to be refilled?

What is the strength (mg.) of the medication?

How much and how often does the child take the medication?

What is the condition or diagnosis for which child is prescribed this medication?

Where do you want the written prescription to be sent?

I consent to my submitted form data being logged, collected and stored.(Required)