patient portal


Medication Refill Request

This form cannot be used for ADD/ADHD refills.

This form is for refill of medication only. You must be a current patient of Northwest Pediatrics. Your prescription will be called in by 6:00 p.m. (assuming you sent the form during our business hours: 8:00 a.m. – 5:00 p.m. Monday through Friday). Any form sent after 3:00 p.m. will be considered next business day. Please call your pharmacy before picking up your prescription to ensure it is ready.

E-mail responses can take up to 24 hours or longer if we would receive your on-line form during the weekend.

If you require a prescription filled sooner, please call 614.766.6321 for the Dublin office or 614.457.6461 for the Upper Arlington office during our business hours. Please use our on-line refill form to request your refill.

For refills, please fill in the information below. Please allow 48 hours.
*Patient's Full Name
*Patient's Date of Birth
*Parent / Guardian Full Name
*Guardian E-mail
*Name of Medication
*Parmacy Phone #
*Dosage Schedule
*Phone # that we can reach you with questions
Anything else we should know about this refill


© 2005 Northwest Pediatrics Inc.