Rx Refill Request - David S. Weingarden, M.D. & Associates, P.C.

Please fill out this form completely.

Please allow at least 48-72 hours after submiting a refill request before calling your pharmacy to see if it is ready for pick-up.

If you have any questions, please feel free to call our office directly at: 586-228-2882.

Patients COMPLETE Name (First, Middle, and Last Name): *

Date of Birth (mm/dd/yyyy): *

What is the patients contact phone number: *

Which Doctor do you see? *

Who is requesting the refill?
SelfSpouseOther

For what medication are you requesting a refill? *

If your Medication was not listed above, please list the medication:

What is the strength?

How often is it taken?

Number of pills per dose?

What is your pharmacies name, location, and phone number? *

Additional notes/comments for your doctor: