HOME STAFF REQUEST AN APPOINTMENT TELEMEDICINE RX REQUEST FORMS TESTIMONIALS RX REQUESTS WILL BE PROCESSED WITHIN 48 HOURS. Patient Information REFILL REQUESTS Adderall Adderall XR Concerta Dexedrine Dextroamphetamine Jornay Metadate Methylphenidate Methylin Mydayis Quillivant XR Ritalin Vyvanse MEDICAL PROVIER Dr. Geenens Marissa Lahey, APRN-BC Dr. Haynes, DNP Submit Request PLEASE NOTE If your medication is not on the list below, DO NOT use this refill request. Instead, please call your pharmacy, and have them fax us a request at fax (913) 890-7285. If you are using a pharmacy for the first time for your prescriptions, please enter the new pharmacy information. Your prescription will be called in by your provider to the new pharmacy. After this, refills can be faxed to our office from that pharmacy. ©2020 Geenens Psychiatry. Proudly made with wix.com

HOME STAFF REQUEST AN APPOINTMENT TELEMEDICINE RX REQUEST FORMS TESTIMONIALS Insurance Card & ID Upload For current patients, if we do not already have a copy of a valid form of ID to have on file or a copy of your insurance card (if applicable), please upload those documents here: Upload Front of Insurance Card Upload Here Upload Back of Insurance Card Upload Here Upload VALID Form of ID (i.e. Driver's License, State ID, or Passport) Upload Here Submit *If you are unable to submit using the button above please email the completed form(s) to: arthurc@geenenspsychiatry.org* ©2020 Geenens Psychiatry. Proudly made with wix.com

HOME STAFF REQUEST AN APPOINTMENT TELEMEDICINE RX REQUEST FORMS TESTIMONIALS Request an Appointment NEW PATIENTS Patients NEW to Geenens Psychiatry (or who have not been seen in over 16 months at Geenens Psychiatry) *After you complete the Form, we will contact you.* NEW PATIENT INTAKE FORM CURRENT PATIENTS Existing Patients, please click the link below to request to schedule your next appointment. DR. DOUGLAS L. GEENENS MARISSA LAHEY, APRN-BC DR. VICTORIA HAYNES *To cancel your appointment, please contact our office at (913) 488-2012 at least 24 hours prior to your appointment in order to avoid a Cancellation Fee. Please refer to our Policies & Procedures if you have any questions.* ©2020 Geenens Psychiatry. Proudly made with wix.com