Allergy Diagnostic & Treatment Center ·33 Overlook Road, Ste #307, Summit N.J. 07901
Voice (908) 522-9696· Fax: (908) 522-3070
Home Page · Billing · Office Hours

Online Prescription Refill Request Form:

To request a prescription refill, please fill out all of the required fields (marked with a *) below. Use the Tab Key to move to the next field, not the Enter key. We will not be able to refill your prescription without the required information. You will receive an email confirmation after submitting this form. Please note: Antibiotic prescriptions will not be refilled online.

Personal Information

First Name*: M.I.: Last*: Birthdate*: Phone # if there is a problem*: E-mail*:

Prescription Information

Drug name and dosage*: Accolate tablets 10 mg Accolate tablets 20 mg Advair 100/50 Advair 250/50 Advair 500/50 Albuterol MDI, inhaler Albuterol unit dose, vials Allegra capsules 60 mg Allegra tablets 30 mg Allegra tablets 60 mg Allegra tablets 180 mg Allegra D tablets Alocril solution 2% Alrex solution 0.2% Axert tablet 6.25 mg Axert tablet 12.5 mg Amerge tablet 2.5 mg Astelin Nasal Spray Celebrex tablets 100 mg Celebrex tablets 200 mg Clarinex-D 12 hr tablets Clarinex-D 24 hr tablets Clarinex tablet 5 mg Clarinex chews 2.5 mg Clarinex chews 5 mg Deconsal II tablets Desowen cream 0.05% Duratuss tablets Duratuss G tablets Elidel cream 1% Elocon Cream 0.1% Epi-Pen injection Epi-Pen Jr. injection Flonase Nasal Spray Flovent 44mcg Flovent 110 mcg Flovent 220 mcg Foradil Aerolizer Humibid LA tablets Imitrex tablets 25 mg Imitrex tablets 50 mg Imitrex tablets 100 mg Imitrex Nasal Spray 5 mg Imitrex Nasal Spray 20 mg Imitrex Injection 6 mg Livostin solution Maxair inhaler Maxalt tablets 5 mg Maxalt tablets 10 mg Nasacort aq spray Nasonex spray Nexium tablets 20 mg Nexium tablets 40 mg Optivar solution 0.05% Other (type in below) Patanol Solution 0.1% Pred MildSolution 0.12% Prednisone tablet 2 mg Prednisone tablet 5 mg Prednisone tablet 10 mg Prednisone tablet 20 mg Prevacid capsules 15 mg Prevacid capsules 30 mg Prilosec 10 mg Protopic Ointment 0.1% Protopic Ointment 0.03% Proventil HFA Inhaler Proventil Unit Dose Vials 0.083% Pulmicort Turbuhaler Q-Var Inhaler 40 mg Q-Var Inhaler 80 mg Rhinocort Aq spray Serevent Inhaler Singular tablets 10 mg Singluar chewables 4 mg Singular chewables 5 mg Triamcinolone cream 0.1% TriNasal nasal spray Tussionex Syrup Xopenex 0.63 mg vial Xopenex 1.25 mg vial Zaditor Solution 0.02% Zomig tablets 2.5 mg Zomig tablets 5.0 mg Zyrtec tablets 5 mg Zyrtec tablets 10 mg Zyrtec D tablets Instructions on use*: 1 2 3 4 5 250mg 300mg 400mg 500mg 600mg 875mg capsule(s) tablet(s) teaspoon(s) puff(s) spray(s) vial(s) other (type in below) 1 x daily 2 x daily 3 x daily 4 x daily every 1 hour every 2 hours every 3 hours every 4 hours every 6 hours every 8 hours every 12 hours daily every other day every third day 1 x week as needed (example: 1 tab 1 x daily, or 1 tab every 4 hours) Quantity requested*: # of refills requested*: 1 2 3 4 5 (example: 30 tablets, 1 inhaler, 1 pack, 4 oz.)

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