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Associated Neurologists in Danbury CT, Southbury CT, and Waterbury CT

Associated Neurologists - Prescription Refill Form

Prescription Refills

Use this form to request prescription refills online. Please note:

  1. All prescriptions will be called in by the end of the next business day.
  2. Emergency prescriptions must be called directly to the office.
  3. Medical questions will not be responded to on the website.
  4. This feature is for established patients only. You must have been seen in our office within the last year to request prescriptions online.

Your request will be sent once you click the "send information" button at the bottom of this page.

Date:
Patient Name:
Person Completing Form:
Relationship to Patient:
Contact E-mail Address:
Contact Method:
Name of Medication:
Milligrams (mg):
Form of Medication:
Times Taken Per Day:
Amount Taken Per Dose:
Length Prescription Needed For:
Pharmacy Name
Pharmacy Phone
Pharmacy Fax
Pharmacy Location (City/State)
Please add any other information here, e.g.
allergies to medications, other medications currently taking, etc.
  

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Associated Neurologists, P.C.
 
Associated Neurologists, Danbury CT Associated Neurologists, Waterbury CT
69 Sand Pit Rd., Suite 300 1389 W. Main St., Suite 212
Danbury, CT 06810 Waterbury, CT 06708
Tel: 203.748.2551 Tel: 203.755.7367
Fax: 203.790.6375 Fax: 203.755.1947
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Southbury Medical Building
22 Old Waterbury Road, Suite 106
(corner of Main Street North)
Southbury, CT 06488
Tel: 203.262.4270
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