Northern Virginia Pediatric Associates, P.C.107 North Virginia Ave, Falls Church, VA 2204624 Hour Phone #: (703) 532-4446 | Fax #: (703) 532-8426By Appointment OnlyMonday - Friday: 8:00 am - 7:00 pmSaturday: 8:00 am - 1:00 pmSunday & Holidays: 9:00 am - 12 pmCopyright © 2017 Northern Virginia Pediatric Associates, P.C. All Rights Reserved.Thank you for using our online forms. Please note that the collected data from online submitted forms will be deleted within 48 business hours by one of our team members for security purposes.
Please fill out this form completely and accurately. Five working days may be needed for prescriptions to be completed. There is a $10.00 charge for ADHD medications and for for lost prescriptions. ADHD medications cannot be called in to the pharmacy
Please, use one form for each prescription.
Child’s Name (last, first)
Date of Birth
Name of medication
Brand or Generic
Form of medication
Dose of medication (include units like mg, ml, etc)
Times given per day
Days needed-per prescription
If ninety days needed: do you want 1 (90) day prescription or 3 (30) day prescriptions?
1 (90) day
3 (30) day
Please check one
Call when prescription is ready for pick up.
Mail prescription to my home address
Mailing Home Address
Your Prescription Procedure AND Refill form has been submitted. Thank you for using the online form.