Email* Cell Phone number*Date* DD slash MM slash YYYY Child's Name. ( DO NOT USE PARENT NAME )* First Last DO NOT USE PARENT NAMEADHD medications. Script ordering and Omega Supplements Collection of Omega 3 productsCertain medical aids cover the following Omega products and supplements, depending on your plan. After successful completion and payment, our staff will contact you regarding collection from our rooms. Your statement can be submitted to medical aid for reimbursement.The Power of Omega-3s to Affect the ADHD BrainImprove symptoms of ADHD and school performance. “There is sufficient evidence to consider omega-3 fatty acids as a supplement to established [medication and behavioural] therapies” in ADHD, the researchers concluded in the journal Clinical Psychology Review. Children diagnosed with ADHD have 38% lower blood levels of omega-3s. Only certain Omega supplements are effective.OmegaGenics® EPA-DHA QuantityFrom 12y ServingsPer Container: 60 Price: R495.00 Quantity MetaKids™ Multi Soft Chew QuantityVitamins • Minerals • Phytonutrients From 2 years. Servings Per Container: 30. Price: R675.00 Quantity This field is hidden when viewing the formDate last follow up DD slash MM slash YYYY This field is hidden when viewing the formMonths since last appointmentThis field is hidden when viewing the formTreatment Plan at last appointmentThis field is hidden when viewing the formAdditional recommendationsThis field is hidden when viewing the formTreatment Plan otherThis field is hidden when viewing the formRecommendationsMedications*Select the type of medication or combination of medications taken per month. Ritalin 10mg tablets (short acting) Ritalin capsules 10mg,20mg,30mg,40mg (Long acting) Medikinet MR capsules 10mg,20mg,30mg,40mg (Long acting) Concerta or Neucon OROS Contramyl XL Vyvanse tablets 30mg, 50mg, 70mg Amfexa tablets 5mg, 10mg, 20mg( short-acting) INIR or Strattera or generic Risperidone or Risperdal or Risperlet Cilift/Cipramil/Lorien/Serdep Melatonin or Circadin Additional chronic medicationsRitalin 10mg(ten) Tablets taken daily* Ritalin 5mg(five) half(1/2) tablet daily and 15(fifteen) per month Ritalin 10mg(ten) one(1) daily and 30(Thirty) per month Ritalin 10mg(ten) one(1) daily and 20(Twenty) per month Ritalin 15mg(fifteen) one and half(1.5) daily and 45(Forty five) per month Ritalin 10mg(ten) two(2) daily and 60(sixty) per month Ritalin 10mg(ten) two and half(2.5) daily and 75(Seventy five) per month Ritalin 10mg(ten) three(3) daily and 90(ninety) per month Ritalin 10mg(ten )four(4) daily and 120(one hundred and twenty) per month Ritalin 10mg(ten) 5(five) daily and 150(one hundred and fifty) per month Ritalin 10mg(ten) 6(six) daily and 180(one hundred and eighty ) per monthRitalin capsules long acting taken daily* Ritalin LA 10mg (ten) daily and 30(thirty) per month Ritalin LA 10mg (ten) 2(two) daily and 60(sixty) per month Ritalin LA 20mg (twenty) daily and 30(thirty) per month Ritalin LA 30mg (thirty) daily and 30(thirty) per month Ritalin LA 40mg (forty) daily and 30 (thirty) per monthMedikinet capsules long acting taken daily* Medikinet MR 5mg (5) daily and 30(thirty) per month Medikinet MR 10mg (ten) daily and 30(thirty) per month Medikinet MR 10mg (ten) 2(two) daily and 60(sixty) per month Medikinet MR 20mg (twenty) daily and 30(thirty) per month Medikinet MR 20mg (twenty) 2(two)daily and 60(sixty) per month Medikinet MR 30mg (thirty) daily and 30(thirty) per month Medikinet MR 40mg (forty) daily and 30 (thirty) per monthConcerta capsules taken daily* Concerta or Neucon OROS 18mg (eighteen) daily and 30(thirty) per month Concerta or Neucon OROS 27mg(twenty seven) daily and 30(thirty per month Concerta or Neucon OROS 36mg (thirty six) daily and 30(thirty) per month Concerta or Neucon OROS 36mg (thirty six) weekends and 8(eight per month) Concerta or Neucon OROS 54mg (fifty four) daily and 30(thirty) per month Concerta or Neucon OROS 54mg (fifty four) week days and 22(twenty two) per monthAmfexa tablets taken daily* Amfexa tablets 5mg (five) daily and 30(thirty) per month Amfexa tablets 5mg (five) twice(2)(daily) and 60(sixty) per month Amfexa tablets 10mg (ten) daily and 30(thirty) per month Amfexa tablets 10mg (ten) twice(2)(daily) and 60(sixty) per month Amfexa tablets 10mg (ten) 1,5(one-and-Half)15mg(fifteen) twice(2)(daily) and 90(ninety) per month Amfexa tablets 20mg (twenty) once(1)(daily) and 30(thirty) per month Amfexa tablets 20mg (twenty) twice(2)(daily) and 60(sixty) per monthVyvanse capsules taken daily* Vyvanse tablets 30mg (thirty) daily and 30(thirty) per month Vyvanse tablets 50mg (fifty) daily and 30(thirty) per month Vyvanse tablets 70mg (seventy) daily and 30(thirty) per monthThere is a nation wide shortage of Vyvanse please discuss with our team the possible alternative or using Amfexa 10mg twice a day if using the Vyvanse 30mg and Amfexa 15mg twice daily if using the Vyvanse 50mg and 70mgContramyl XL capsules taken daily* Contramyl XL 18mg (eighteen) daily and 30(thirty) per month Contramyl XL 27mg(twenty seven) daily and 30(thirty per month Contramyl XL 36mg (thirty six) daily and 30(thirty) per month Contramyl XL 36mg (thirty six) weekends and 8(eight per month) Contramyl XL 54mg (fifty four) daily and 30(thirty) per month Contramyl XL 54mg (fifty four) week days and 22(twenty two) per monthStrattera capsules Strattera or INIR or Generic 10mg (ten) daily and 30(thirty) per month Strattera or INIR or Generic 18mg (eighteen) daily and 30(thirty per month Strattera or INIR Generic 25mg (twenty five) daily and 30(thirty) per month Strattera or INIR Generic 40mg (forty) daily and 30(thirty) per month Strattera or INIR Generic 60mg (sixty) daily and 30(thirty) per monthRispiradone / Risperdal 0,5mg (half)tablets or liquid(ml)* Rispiradone 0,25mg(quarter) daily and 15(fifteen) tablets per month Rispiradone 0,25mg(quarter) twice(2)daily and 30(thirty) tablets per month Rispiradone 0,5mg(half) daily and 30(thirty) tablets per month Rispiradone 0,5mg(half) twice(2)daily and 60(sixty) tablets per month Rispiradone 1mg(one) once(1)daily and 30(thirty) tablets per month Rispiradone 0,25ml(quarter) once (1) or twice(2)daily 15ml (fifteen) per month Rispiradone 0,5ml(Half) once (1) or twice(2)daily 30ml (thirty)per month Rispiradone 0,2ml(zero point 2ml) once (1) daily 6ml (six)per month Rispiradone 0,2ml(zero point 2ml) twice (2) daily 12ml (twelve)per monthCilift or Cipramil or Lorien or Serdep* Cilift 10mg daily for one month Cilift 20mg daily for one month Serdep 25mg daily for one month Serdep 50mg daily for one month Serdep 100mg daily for one month Cipramil 10mg daily for one month Cipramil 20mg daily for one month Lorien 10mg daily for one month Lorien 20mg daily for one monthMelatonin or CircadinAdditional medication*Name of medicationdose per tablet or dose per 5mlNumber of times taken per dayNumber of tablets per day or ml per dayTotal number of tablets or ml per month Number of scripts( Max 3 since last appointment) Quantity* Price: R140.00 Quantity Please note additional scripts can only be ordered if your child has been seen within the last 4 months. All children must be seen every 4 months for a consultation. RITALIN, CONCERTA AND RISPERDAL SCRIPTS CAN ONLY BE ISSUED FOR ONE MONTH. ADDITIONAL SCRIPTS CAN BE ISSUED AS PRE-DATED SCRIPTS. EACH ADDITIONAL SCRIPT WILL BE CHARGED FOR. THIS IS A SOUTH AFRICAN LEGAL REQUIREMENT FOR SCHEDULE 5& 6 MEDICATIONS. All other mediation can be repeated.Total R0.00 This field is hidden when viewing the formNumber of Monthly scripts required* RITALIN, CONCERTA AND RISPERDAL SCRIPTS CAN ONLY BE ISSUED FOR ONE MONTH. ADDITIONAL SCRIPTS CAN BE ISSUED AS PRE-DATED SCRIPTS. EACH ADDITIONAL SCRIPT WILL BE CHARGED FOR. THIS IS A SOUTH AFRICAN LEGAL REQUIREMENT FOR SCHEDULE 5& 6 MEDICATIONS. All other mediation can be repeated.Please enter a number from 1 to 3.Pharmacies ( Please select carefully as your selection cannot be reversed.)*Select the pharmacy where you would like your prescription to be sent.Alpha Pharm, Christian's/P n P Centre, HillcrestAlph Pharm UmdoniAlpha Pharm GlenashleyAshley Pharmacy, Ashley PinetownBhamjees Pharmacy, RichmondBonnie Doon Pharmacy, East LondonBroadway Pharmacy, Durban NorthBrownsdrift Pharmacy, Durban NorthCentral Pharmacy, Durban CentralClicks, Amajuba MallClicks, Bluff LighthouseClicks, Cascades, PMBClicks, Delcairn Centre, KloofClicks, Gonubie, East LondonClicks, KokstadClicks Pharmacy, Hillcrest CornerClicks, La LuciaClicks, Lillies Quarter, HillcrestClicks, Malvern Park Shopping CentreClicks Pharmacy, Umhlali (Tiffany's Centre)Clicks, Queensburgh Shopping CentreClicks, South Coast MallClicks, The Crescent, UmhlangaClicks, Village Mall, KloofClicks, Village Market, WestvilleClicks WatercrestClicks Westville Village MallClubville Pharmacy, MiddelburgConstantia Pharmacy, Cape TownCylnor Pharmacy, Somerset WestDalton Pharmacy (Alpha Pharm)Die Boord Pharmacy, StellenboschDischem, Atrium Centre, OverportDischem Ballito (Junction)Dischem Ballito LifestyleDischem BluffDischem, Cascades, PMBDischem Castle Gate, Erasmus, PretoriaDischem CenturionDischem, Chartwell, DainfernDischem ClearwaterDischem, Cornubia, UmhlangaDischem GalleriaDischem, GatewayDischem, Hillcrest CornerDischem HemmingwaysDischem, HowickDischem, IreneDischem La LuciaDischem, Lynnwood Rd, Hatfield, PretoriaDischem Mall 55, PretoriaDischem, Malvern ParkDischem Midlands MallDischem, Morningside Sandton Surgical Centre, Jo'burgDischem MusgraveDischem, NewcastleDischem, NorthlandsDischem PavilionDischem PearlsDischem Pearls UmhlangaDischem PinecrestDischem, Richard's BayDischem, Sandton CityDischem ScottburghDischem, Sea PointDischem South Coast MallDischem, SpringfieldDischem, Springfield ParkDischem, The Avenues, HiltonDischem, Toti CentreDischem, Valley View, KrugersdorpDischem WatercrestDischem Westville JunctionDischem Westville (Westwood Mall)Dischem WoodburnDischem Wonderboom Junction, PretoriaDischem, York Street Pharmacy, GeorgeEikestad Pharmacy, StellenboschFamcare Pharmacy, East LondonFields Pharmacy, KloofGillitts PharmacyGowrie Pharmacy, Nottingham RdGraceMed Pharmacy, Shelly BeachGreytown Healthcare PharmacyHarding Pharmacy, South CoastHayfields PharmacyHillcrest Medical Centre DispensaryHilton Local Choice (Life Hilton Hosp)Howick Village PharmacyInfo Med Pharmacy, CamperdownIxopo PharmacyJan Hofmeyr Pharmacy, WestvilleKokstad PharmacyKwikspar Pharmacy, Westerford, Cape TownLink Hills PharmacyLongbury Pharmacy, PhoenixMarine Drive Pharmacy, BluffMaximed Pharmacy, StandertonMedcare Pharmacy, OverportMedirite, ChatsworthMedirite St. John'sMedisport Pharmacy, UmhlangaMigamed Pharmacy, Spar, Port EdwardMitchell Park PharmacyMount Edgecombe PharmacyMtuba PharmacyNorthway Pharmacy, Durban NorthParadise Junction Pharmacy, PinetownPelican Pharmacy (Prime Cure), ChatsworthPeople's Pharmacy, PinetownPharmacy at Spar Livewell, Bothas HillPharmacy at Spar, Hillcrest (Richden's)Pierau Pharmacy, WinkelspruitReservoir Hills PharmacyRemed Pharmacy, LadysmithSani Pharmacy, UnderbergScott Street PharmacyScottsville Pharmacy, PMBShentons Pharmacy, QueensburghShepmed Pharmacy, PinetownStelkor Kampus Pharmacy, StellenboschSunningdale PharmacyThe Local Choice, Heritage/Oxford Ctr HillcrestThe Local Choice, Pinelands, PinetownThrive Pharmacy, BallitoThrive Pharmacy, KloofTown Bush PharmacyTugela PharmacyTweni Pharmacy, MtunziniTyrone Pharmacy, Parkview, JhbVal de Vie, The Local Choice, PaarlVan der Nest Pharmacy, VryheidWembley PharmacyWindermere PharmacyWinston Park PharmacyWinterton, The Local ChoicePlease select carefully as your selection cannot be reversed.This field is hidden when viewing the formPharmacy*For the duration of the lock down all DIschem pharmacies are authorised to accept schedule 5 and 6 medications scripts directly emailed by myself. This avoids the need to collect the originals.Email of the Pharmacy to send scripts or your own email address* If no email is included scripts will need to be collected from my rooms or the Hospital.Terms and conditions* View terms and conditions I have read and accepted terms and conditions.This field is hidden when viewing the formUse our new APP to order scripts.Tap or scan QR codeTerms and ConditionsAll reasonable steps have been taken to ensure that the script is available for collection, and if legally permitted during the COVID19 pandemic, the script will be emailed directly to the pharmacist. Should the script be lost, misplaced, not collected, alterations to the dosing at your or the teacher’s request/advice, change of pharmacy or expire an additional script fee will apply. To prevent any misunderstanding, please note: We do not send accounts to Medical Aid unless specifically requested with Dr. Flett. Fees are charged at Discovery Executive Package Medical Aid rates. If you are not on this plan, your medical aid may not cover the full fee. They pay a benefit based on the cover you have chosen. Please note weekend and after hour services are charged at higher rates and rates are dependent on complexity and hours of service.Patients must pay at consultation. Due to increasing bad debt, administration and legal costs, the following conditions apply (office hours):• Invoices are due on presentation • We do not phone medical aids • You are responsible for settlement of fees charged regardless of whether we do/do not submit the invoice to Medical aid. • If Medical Aid pays you, please pay us within 7 days of receipt of payment. • It is advised that you monitor all invoices with your medical aid.We do not ‘write off’ unpaid fees. All accounts in default (as detailed above) are referred to our Attorney for recovery. You will be liable for all costs on an attorney-own client basis. Missed appointments not cancelled within 24 hours will be charged for. These terms and conditions automatically apply to all your dependents whether listed or not.Your de-identified information may be used for epidemiological, research, or practice business planning and may be passed on in a de-identified format to third parties for further processing. For the accuracy of health care planning, it is important that as much information as possible included in these types of analyses and that your participation in this regard is highly appreciated. I understand the implications and agree, where appropriate, to the doctor and practice disclosing my ICD-10 diagnostic code under the conditions described above. I accept these conditions. I confirm that I am not under an administration or insolvency order. I nominate my residential address as recorded alongside to be my domicilium citandi et executandi. I consent to the jurisdiction of the Magistrate Court in Durban notwithstanding the amount of the claim against me.After submission of this form you will be directed to a payment Gateway. Please note no script will be processed until payment has been received.