*Select all that apply
New Medication Requesting authorization on existing medication
Select all that apply
Selet a monitoring plan and edit if necessary, or select the blank box and write your own
For any other information about the medication you want to provide
Planned Medication #2
Planned Medication #3
Planned Medication #4
Planned Medication #5
Planned Medication #6
Planned Medication #7
Planned Medication #8
*Physical exam
Physical exam completed and normal Physical exam completed and following abnormalities:
No other medical problems
Is the child currently on other psychotropic medications?
(Use only if a preconsent was already obtained, otherwise add in Section 3)
1) Amount: Unit: Please select optionmgmlOther Frequency: Please select optionOnce dailyTwice dailyThree times dailyFour times dailyAs neededAt bedtimeOther Range:
2) Amount: Unit: Please select optionmgmlOther Frequency: Please select optionOnce dailyTwice dailyThree times dailyFour times dailyAs neededAt bedtimeOther Range:
3) Amount: Unit: Please select optionmgmlOther Frequency: Please select optionOnce dailyTwice dailyThree times dailyFour times dailyAs neededAt bedtimeOther Range:
4) Amount: Unit: Please select optionmgmlOther Frequency: Please select optionOnce dailyTwice dailyThree times dailyFour times dailyAs neededAt bedtimeOther Range:
Is the child on any other non-psychotropic medications (including over the counter)?
1) 2)