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*: MI: Last*:
Birthdate*: Phone # if there is a problem*:
Email*:

Prescription Information
Drug name and dosage*:
Instructions on use*:
  (example: 1 tab 1 x daily, or 1 tab every 4 hours)
Quantity Requested*: # of refills requested*:
  (example: 30 tablets, 1 inhaler, 1 pack, 4 oz.)

Pharmacy Information
Your message/additional information (optional):
What is five plus five? (spelled out)*: