Healthcare Prescription Adderall Form

Healthcare Prescription Adderall Form

Patient Information

Date of Birth:    Gender: Male   Female   Other

Insurance Information

Medical History

Prescription Details

Medication:    Strength:

Dosage Form:    Quantity:    Directions:

Number of Refills Authorized (if any):

Prescription Date:    Indication/Diagnosis:

Controlled Substance Notices and Consent

I acknowledge that Adderall is a Schedule II controlled substance with a risk of dependence, misuse, and diversion. I understand that the prescriber will evaluate therapeutic benefit, monitor for adverse effects, and may discontinue treatment if risks outweigh benefits.

I consent to the prescriber checking prescription monitoring program records, obtaining prior medication records from pharmacies, and ordering urine drug screening or other tests as clinically indicated to verify adherence and detect undisclosed substance use.

I will not share, sell, or provide this medication to any other person. I understand that obtaining controlled substances from multiple providers or pharmacies constitutes diversion and may result in termination of controlled substance prescribing by this practice.

I agree to secure medication in a safe location, to dispose of unused medication through recommended safe disposal methods, and to report lost or stolen medications to the prescriber and law enforcement as required. Early refill requests will be evaluated and may be denied.

Pregnancy and lactation: I was advised to notify my prescriber if I am pregnant, planning pregnancy, or breastfeeding. Use of stimulants during pregnancy or lactation has potential risks that should be discussed with my provider.

Patient Acknowledgment

By signing this form I acknowledge that I have read and understand the information above, have had an opportunity to ask questions, and consent to treatment with a stimulant medication as prescribed. I understand that I may withdraw consent at any time by notifying my prescriber, but withdrawal may require alternative treatment planning.

Provider Attestation

Prescriber Name:    DEA Number:

NPI:    State License:

Office Phone:    Fax:

Authorization and Expiration

This authorization to prescribe a Schedule II stimulant is effective on:    and will expire on:

I acknowledge that continuation of therapy is contingent upon periodic clinical evaluation, monitoring, and compliance with clinic policies and applicable law. I understand that failure to comply may result in tapering or discontinuation of the medication.

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