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.

Please fill out the following contact form with patient information, main concerns, and the type of appointment you need (evaluation for a new diagnosis, follow-up care, integrative treatment, or neurofeedback therapy).
You may also send a copy of your insurance card and photo ID to Reception@HolisticDevelopmentalPeds.com or fax to 210-403-2350.

Contact Info:

Full Name: (required)

E-mail: (required)

Phone: (required)

Address:

Address 2:

City:

State:

Zip:

Patient Info:

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:

Non-controlled medication requested (name, dose/unit, how many/dose, how many times/day and times of dose):

How is the medication working? Other questions, comments, or concerns:

Please leave this field empty.