Need Help?There is NO question that is too small. If there is a concern, then act on your parental instinct and get help! We are here to solve your concernEmail* Cell Phone number*Date* Date Format: DD slash MM slash YYYY Child's Name* First Last Medications*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) Concerta or Neucon OROS Contramyl XL Strattera or generic Risperidone or Risperdal or Risperlet Cilift/Cipramil/Lorien 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 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 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 monthContramyl 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 Select All Strattera or Generic 10mg (ten) daily and 30(thirty) per month Strattera or Generic 18mg (eighteen) daily and 30(thirty per month Strattera or Generic 25 (twenty five) daily and 30(thirty) per month Strattera or Generic 40mg (forty) daily and 30(thirty) per month Strattera or Generic 60mg (sixty) daily and 30(thirty) per monthRispiradone / Risperdal 0,5mg (half)tablets* 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 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 monthCilift or Cipramil or Lorien* Cilift 10mg daily for one month Cilift 20mg 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 Scripts Price: R120.00 Number of repeat scripts( Max 3 since last appointment)*Please enter a number from 1 to 3.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 Number 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.PharmaciesDischem WatercrestDischem Hillcrest CornerOther PharmacyFor 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.Pharmacy*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 conditionsI have read and accepted terms and conditions.Terms 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.