David S. Weingarden, M.D. & Associates, P.C.

Rx Refill Request Form

Prescription Refill Request for the Office of Doctors':

David S. Weingarden, MD; Gail Soo-Hoo Williams, MD; Geoffrey K. Seidel, MD; David K. Davis, MD; Lawrence R. Blaty, MD; Jagmohan Sharma, MD; Isaac Turner, MD; Diana R. Nadeau, M.D.

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 Name, Middle Initial, 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?
Self
Spouse
Other
*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: The number of pills per dose? *What is your Pharmacy Name, Location, and Phone Number? Additional Notes/Comments for your doctor:

David S. Weingarden, M.D. & Associates, P.C.

Physical Medicine & Rehabilitation / Neurology

Rx Refill Request Form