Submit a request – ADHD Online

Please choose your issue below

Your email address

Ticket Processing Time

2-3 Business Days

To check the status of your request, please log into your patient portal.

If you have waited the recommended processing time, you may use the chat feature in your patient portal to check the status of your request.

Subject

Are you the Patient or Parent/Guardian?

Patient's First and Last Name

Please enter the patient name if filling out for someone else

Patient's Date of Birth

Phone Number

Please enter your personal number here

Home address

In order to fill your prescription, the pharmacy needs your correct address. If this information has changed, please upload an ID or verification.

How can we help you with your appointment? (optional)

Please indicate the date and time of your appointment:

Future appointments older than 24 hours can be rescheduled for a future date in the patient portal at no extra cost. Future appointments canceled over 24 hours in advance will result in a full refund.

Reason for Rescheduling:

Please indicate why you need assistance.

Additional Details

Please list any additional details that you would like us to know.

Please tell us your provider's name, the date, and the time of your appointment:(optional)

We encourage all patients to wait at least 10 minutes for their provider to join the meeting room after the scheduled appointment time. Do not leave the virtual waiting room once you have joined.

Preferred Call Back Time

Please select the time frame that is most convenient for you:

By checking the box, I understand that missed appointments and appointments cancelled under 24 hours without notice are subject to a $50 fee.

Appointments that are currently scheduled at least 24 hours in advance can be rescheduled through the patient portal at no extra cost.

Attachments(optional)

Add file or drop files here