Prescription Refills Use this form to request prescription refills online. Please note: All prescriptions will be called in by the end of the next business day. Emergency prescriptions must be called directly to the office. Medical questions will not be responded to on the website. 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: contact me by: e-mail phone Name of Medication: Milligrams (mg): Form of Medication: tablet capsule liquid other Times Taken Per Day: 1 2 3 4 5 6 7 8 Amount Taken Per Dose: 1 2 3 4 5 6 7 8 Length Prescription Needed For: 30 days 60 days 90 days 120 days 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.

	Please Complete Our Feedback Form Associated Neurologists, P.C.   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 view map view map   Southbury Medical Building 22 Old Waterbury Road, Suite 106 (corner of Main Street North) Southbury, CT 06488 Tel: 203.262.4270 view map how to contact us
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