{"id":1623,"date":"2022-02-02T11:59:01","date_gmt":"2022-02-02T11:59:01","guid":{"rendered":"https:\/\/www.toplinemd.com\/pediatric-pros\/?page_id=1623"},"modified":"2022-07-19T11:34:02","modified_gmt":"2022-07-19T11:34:02","slug":"medication-refills","status":"publish","type":"page","link":"https:\/\/www.toplinemd.com\/pediatric-pros\/medication-refills\/","title":{"rendered":"Request Medication Refills"},"content":{"rendered":"<p><div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-1 fusion-flex-container fusion-parallax-none nonhundred-percent-fullwidth non-hundred-percent-height-scrolling\" style=\"--awb-background-position:right center;--awb-border-radius-top-left:0px;--awb-border-radius-top-right:0px;--awb-border-radius-bottom-right:0px;--awb-border-radius-bottom-left:0px;--awb-min-height:400px;--awb-background-image:url(&quot;https:\/\/www.toplinemd.com\/pediatric-pros\/wp-content\/uploads\/sites\/120\/2021\/10\/prenatal-visit-1920-x-400.jpg&quot;);--awb-background-size:cover;--awb-flex-wrap:wrap;\" ><div class=\"fusion-builder-row fusion-row fusion-flex-align-items-center fusion-flex-justify-content-center fusion-flex-content-wrap\" style=\"max-width:1216.8px;margin-left: calc(-4% \/ 2 );margin-right: calc(-4% \/ 2 );\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-0 fusion_builder_column_3_4 3_4 fusion-flex-column\" style=\"--awb-padding-top:20px;--awb-padding-bottom:20px;--awb-bg-color:rgba(54,180,229,0.4);--awb-bg-color-hover:rgba(54,180,229,0.4);--awb-bg-size:cover;--awb-width-large:75%;--awb-margin-top-large:0px;--awb-spacing-right-large:2.56%;--awb-margin-bottom-large:0px;--awb-spacing-left-large:2.56%;--awb-width-medium:100%;--awb-order-medium:0;--awb-spacing-right-medium:1.92%;--awb-spacing-left-medium:1.92%;--awb-width-small:100%;--awb-order-small:0;--awb-spacing-right-small:1.92%;--awb-spacing-left-small:1.92%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><div class=\"fusion-title title fusion-title-1 fusion-title-center fusion-title-text fusion-title-size-one fusion-animated\" style=\"--awb-margin-top-small:0px;--awb-margin-right-small:0px;--awb-margin-bottom-small:20px;--awb-margin-left-small:0px;--awb-font-size:40px;\" data-animationType=\"fadeInUp\" data-animationDuration=\"0.5\" data-animationOffset=\"top-into-view\"><div class=\"title-sep-container title-sep-container-left\"><div class=\"title-sep sep- sep-solid\" style=\"border-color:#e0dede;\"><\/div><\/div><span class=\"awb-title-spacer\"><\/span><h1 class=\"fusion-title-heading title-heading-center fusion-responsive-typography-calculated\" style=\"margin:0;font-size:1em;--fontSize:40;line-height:1.15;\">REQUEST MEDICATION REFILLS<\/h1><span class=\"awb-title-spacer\"><\/span><div class=\"title-sep-container title-sep-container-right\"><div class=\"title-sep sep- sep-solid\" style=\"border-color:#e0dede;\"><\/div><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-2 fusion-flex-container nonhundred-percent-fullwidth non-hundred-percent-height-scrolling padding-wrapper-responsive\" style=\"--awb-border-radius-top-left:0px;--awb-border-radius-top-right:0px;--awb-border-radius-bottom-right:0px;--awb-border-radius-bottom-left:0px;--awb-padding-top:5%;--awb-padding-bottom:5%;--awb-flex-wrap:wrap;\" id=\"button-fix-form\" ><div class=\"fusion-builder-row fusion-row fusion-flex-align-items-flex-start fusion-flex-justify-content-center fusion-flex-content-wrap\" style=\"max-width:calc( 1170px + 0px );margin-left: calc(-0px \/ 2 );margin-right: calc(-0px \/ 2 );\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-1 fusion_builder_column_5_6 5_6 fusion-flex-column padding-box \" style=\"--awb-padding-top:45px;--awb-padding-right:45px;--awb-padding-bottom:45px;--awb-padding-left:45px;--awb-bg-color:#ffffff;--awb-bg-color-hover:#ffffff;--awb-bg-size:cover;--awb-width-large:83.3333333333%;--awb-margin-top-large:0px;--awb-spacing-right-large:0px;--awb-margin-bottom-large:0px;--awb-spacing-left-large:0px;--awb-width-medium:100%;--awb-order-medium:0;--awb-spacing-right-medium:0px;--awb-spacing-left-medium:0px;--awb-width-small:100%;--awb-order-small:0;--awb-spacing-right-small:0px;--awb-spacing-left-small:0px;\" id=\"request-prenatal-visit\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-center fusion-content-layout-column\"><div class=\"fusion-separator fusion-full-width-sep\" style=\"align-self: center;margin-left: auto;margin-right: auto;margin-top:10px;margin-bottom:10px;width:100%;\"><\/div><div class=\"fusion-title title fusion-title-2 fusion-title-center fusion-title-text fusion-title-size-three\" style=\"--awb-margin-bottom:40px;--awb-margin-top-small:0px;--awb-margin-right-small:0px;--awb-margin-bottom-small:20px;--awb-margin-left-small:0px;\"><div class=\"title-sep-container title-sep-container-left\"><div class=\"title-sep sep- sep-solid\" style=\"border-color:#e0dede;\"><\/div><\/div><span class=\"awb-title-spacer\"><\/span><h3 class=\"fusion-title-heading title-heading-center fusion-responsive-typography-calculated\" style=\"margin:0;--fontSize:24;--minFontSize:24;line-height:1.3;\">Request Medication Refills Form<\/h3><span class=\"awb-title-spacer\"><\/span><div class=\"title-sep-container title-sep-container-right\"><div class=\"title-sep sep- sep-solid\" style=\"border-color:#e0dede;\"><\/div><\/div><\/div><div class=\"fusion-text fusion-text-1\"><p style=\"text-align: center;\">Refills will be granted to patients who are up-to-date with their annual checkups. Please allow 48-72 hours for refill to be placed. You will receive an email when the prescription is sent to the pharmacy.<\/p>\n<\/div>\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f1622-o1\" lang=\"en-US\" dir=\"ltr\" data-wpcf7-id=\"1622\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/pediatric-pros\/wp-json\/wp\/v2\/pages\/1623#wpcf7-f1622-o1\" method=\"post\" class=\"wpcf7-form init\" aria-label=\"Contact form\" novalidate=\"novalidate\" data-status=\"init\">\n<fieldset class=\"hidden-fields-container\"><input type=\"hidden\" name=\"_wpcf7\" value=\"1622\" \/><input type=\"hidden\" name=\"_wpcf7_version\" value=\"6.1.6\" \/><input type=\"hidden\" name=\"_wpcf7_locale\" value=\"en_US\" \/><input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f1622-o1\" \/><input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/><input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/><input type=\"hidden\" name=\"_wpcf7_recaptcha_response\" value=\"\" \/>\n<\/fieldset>\n<div class=\"app-form medication-form\">\n\t<div class=\"section1\">\n\t\t<div class=\"app cf7-first-name third\">\n\t\t\t<p><label> First Name: * <span class=\"wpcf7-form-control-wrap\" data-name=\"first-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"First Name\" value=\"\" type=\"text\" name=\"first-name\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"app cf7-last-name third\">\n\t\t\t<p><label> Last Name: * <span class=\"wpcf7-form-control-wrap\" data-name=\"last-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Last Name\" value=\"\" type=\"text\" name=\"last-name\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"app cf7-last-name third\">\n\t\t\t<p><label> Date of Birth: * <span class=\"wpcf7-form-control-wrap\" data-name=\"your-bdate\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Date of Birth\" value=\"\" type=\"date\" name=\"your-bdate\" \/><\/span> <\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"section2\">\n\t\t<div class=\"app cf7-first-name half left\">\n\t\t\t<p><label> Phone Number: * <span class=\"wpcf7-form-control-wrap\" data-name=\"phone-num\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-tel\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Phone Number\" value=\"\" type=\"tel\" name=\"phone-num\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"app cf7-last-name half right\">\n\t\t\t<p><label> Email: * <span class=\"wpcf7-form-control-wrap\" data-name=\"your-email\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-email wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-email\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Email\" value=\"\" type=\"email\" name=\"your-email\" \/><\/span> <\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"section2\">\n\t\t<div class=\"app cf7-first-name half left\">\n\t\t\t<p><label> Specific Medication Name and Dosage * <span class=\"wpcf7-form-control-wrap\" data-name=\"meditation\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Specific Medication Name and Dosage\" value=\"\" type=\"text\" name=\"meditation\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"app cf7-last-name half right\">\n\t\t\t<p><label> Who is your physician at our office?: * <span class=\"wpcf7-form-control-wrap\" data-name=\"doctors\"><select class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\" name=\"doctors\"><option value=\"\">-<\/option><option value=\"Dr. Mark Ginsburg\">Dr. Mark Ginsburg<\/option><option value=\"Dr. Lisa Miller\">Dr. Lisa Miller<\/option><option value=\"Dr. Karen Lee Kuhn\">Dr. Karen Lee Kuhn<\/option><option value=\"Dr. Jana Myers\">Dr. Jana Myers<\/option><option value=\"Dr. Patricia Jimenez Rivero\">Dr. Patricia Jimenez Rivero<\/option><option value=\"Dr. Macie Hurtado\">Dr. Macie Hurtado<\/option><option value=\"Lourdes Roiz, APRN\">Lourdes Roiz, APRN<\/option><\/select><\/span> <\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"full-section\">\n\t\t<div class=\"app form-full\">\n\t\t\t<p><label> Are you doing well on your current dose of medication? * <span class=\"wpcf7-form-control-wrap\" data-name=\"dose-meditation\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Are you doing well on your current dose of medication?\" value=\"\" type=\"text\" name=\"dose-meditation\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"app form-full\">\n\t\t\t<p><label> Have there been any changes in your health since the last prescription? * <span class=\"wpcf7-form-control-wrap\" data-name=\"last-prescription\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Have there been any changes in your health since the last prescription?\" value=\"\" type=\"text\" name=\"last-prescription\" \/><\/span> <\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"section1\">\n\t\t<div class=\"app cf7-first-name third\">\n\t\t\t<p><label> Pharmacy name: * <span class=\"wpcf7-form-control-wrap\" data-name=\"pharmacy-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Pharmacy name\" value=\"\" type=\"text\" name=\"pharmacy-name\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"app cf7-last-name third\">\n\t\t\t<p><label> Pharmacy number * <span class=\"wpcf7-form-control-wrap\" data-name=\"pharmacy-number\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Pharmacy number\" value=\"\" type=\"text\" name=\"pharmacy-number\" \/><\/span><\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"app cf7-last-name third\">\n\t\t\t<p><label> Pharmacy address and zip code * <span class=\"wpcf7-form-control-wrap\" data-name=\"pharmacy-address\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Pharmacy address and zip code\" value=\"\" type=\"text\" name=\"pharmacy-address\" \/><\/span> <\/label>\n\t\t\t<\/p>\n\t\t<\/div>\n\t<\/div>\n\t<p><input class=\"wpcf7-form-control wpcf7-submit has-spinner\" type=\"submit\" value=\"Submit\" \/>\n\t<\/p>\n<\/div><p style=\"display: none !important;\" class=\"akismet-fields-container\" data-prefix=\"_wpcf7_ak_\"><label>&#916;<textarea name=\"_wpcf7_ak_hp_textarea\" cols=\"45\" rows=\"8\" maxlength=\"100\"><\/textarea><\/label><input type=\"hidden\" id=\"ak_js_1\" name=\"_wpcf7_ak_js\" value=\"130\"\/><script>\ndocument.getElementById( \"ak_js_1\" ).setAttribute( \"value\", ( new Date() ).getTime() );\n<\/script>\n<\/p><input type='hidden' class='wpcf7-pum' value='{\"closepopup\":false,\"closedelay\":0,\"openpopup\":false,\"openpopup_id\":0}' \/><div class=\"fusion-alert alert custom alert-custom fusion-alert-center wpcf7-response-output fusion-alert-capitalize awb-alert-native-link-color alert-dismissable awb-alert-close-boxed\" style=\"--awb-border-top-left-radius:0px;--awb-border-top-right-radius:0px;--awb-border-bottom-left-radius:0px;--awb-border-bottom-right-radius:0px;\" role=\"alert\"><div class=\"fusion-alert-content-wrapper\"><span class=\"fusion-alert-content\"><\/span><\/div><button type=\"button\" class=\"close toggle-alert\" data-dismiss=\"alert\" aria-label=\"Close\">&times;<\/button><\/div>\n<\/form>\n<\/div>\n<\/div><\/div><\/div><\/div><\/p>\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":13,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"100-width.php","meta":{"footnotes":"","_links_to":"","_links_to_target":""},"class_list":["post-1623","page","type-page","status-publish","hentry"],"aioseo_notices":[],"aioseo_head":"\n\t\t<!-- All in One SEO 5.0.0.1 - aioseo.com -->\n\t<meta name=\"description\" content=\"REQUEST MEDICATION REFILLS Request Medication Refills Form Refills will be granted to patients who are up-to-date with their annual checkups. 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