Jeri Penkava | Established Patient Prescription Request
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Established Patient Prescription Request

Fill this contact form for prescription refill requests, medication questions, prior authorization requests, lab orders, or if you need a referral for therapies or another specialist. Controlled medication requests are processed on Mondays and the prescription will be available for mailing or pick-up on Tuesday. Please have your refill request sent by Monday opening (9AM). There is a $10.00 fee for controlled medication prescription handling and documentation in between appointments.


    By submitting this form, you are requesting to be contacted by Holistic Developmental Behavioral Pediatrics and Integrative Medicine via phone, email, or SMS regarding your request. SMS consent is collected through the checkbox below.

    Full Name: (required)

    E-mail: (required)

    Phone: (required)

    Address:

    Address 2:

    City:

    State:

    Zip:

    Full Name: (required)

    Birth Month:

    Birth Day:

    Birth Year:

    Current Insurance:

    Guarantor:

    Policy or ID #:

    RX Bin/PCN/Group #:

    Controlled medication requested:

    Other:

    30-60-90 day:

    Check one:BrandGeneric

    Mg/unit:

    Other:

    Form:

    How many / dose and times / day:



    Name of pharmacy: (required)

    Address/zip code: (required)

    Phone #: (required)


    Consent is not a condition of purchase. We do not share your information with third parties.
    See our Privacy Policy and Terms & Conditions.