Request Prescription Adjustment

Let's Adjust Your Meds!

Please complete the below required fields so we can make this change for you.
Are you an AutoPsych Member?*

YesNo
Please Enter Your Name:*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Email Address
example@example.com
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone*
Please enter a valid phone number.
Let's Make This Happen

Please indicate the change you would like to make, whether it's starting a new medication, changing existing medications, or switching to an alternative.
Please select the medication you would like to change*
Please indicate what change you would like to make:*

Increase the doseDecrease the doseDiscontinue the medicationStart new medicationSwitch to an alternative medicationOther
Please select the symptom(s) you would like to address*

Difficulties with focus and concentration(ADHD)Poor sleep(Insomnia)Worrying too much(Anxiety)Other
Please select the reason we are making this change

Not working well enoughNew problem that needs to be addressedToo many side effectsOther
If you would like to start a new medication. Please select that medication here:
If you're starting a new medication, please tell us how you would like to start

I would like to start at the standard starting doseI would like to start at an equivalent dose to the l medication I am stoppingOther
Preferred Pharmacy*

Same as last timeOther
Informed Consent:

Please tap here for immediate access to an evidence based, public resource to learn more about these medications. Including mechanisms of action, benefits, risks and potential side effects.
Okay almost done!

Please sign below to verify you are in agreement to make the above medication changes, that you understand the risks and benefits of taking this medication, and that you agree to move forward today.
Patient(or parent/guardian) Signature:*

Powered by Jotform SignClear

Please complete payment here:*

Medication AdjustmentService includes comprehensive chart review, adjusted prescription submission, with ongoing care and monitoring with the AutoPsych provider team.

$29.99 Quantity

Total

$0.00

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Should be Empty:

Let's Adjust Your Meds!

Let's Make This Happen

Okay almost done!