James M. Parolie, MD
James W. Dwyer, MD
Paul P. Vessa, MD
Mingi Choi, MD

PRESCRIPTION REFILL FORM

If you would like to make an online request for a prescription refill given to you by a Somerset physician, please submit the information requisition below. A prescription nurse will confirm your request with your doctor, and your request; if approved, will be called in to your pharmacy within 48 hours. If you submit a request after hours or on weekends, it will be addressed on the next business day. Prescription refill requests made online will only be honored if an active prescription, and approved by your doctor.

Somerset Orthopedics maintains the following policy regarding prescription requests made by phone and online: We will not fill prescription requests made after hours, on holidays or on weekends. Please plan ahead if you are running out of medications. While we try to address every request in a timely manner, it may be the next business day before your request can be honored. Thank you for your understanding.

All fields except "Email" and "Additional Info" are required.

Patient's Last Name:

First Name:

Birthdate:

Email Address:

Patient's Phone:

Physician:

Name of Medicine:

Name of Pharmacy:

Pharmacy Phone #:

List any drug allergies : (Write "none" if none)

Additional Information you'd like us to know:



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1 Robertson Dr. • Bedminster, NJ 07921
Phone: (908) 722-0822 • Fax: (908) 722-6318
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