Neurology Department Online Refill Request Form

We are unable to refill medications if the patient has not had an office visit within the past six (6) months. Please call 888-884-BEAR (2327) to schedule an appointment.

If the patient has had an office visit within the past six (6) months, please read the Prescription Refill Instructions before using the form below.

Contact Information
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Patient Information
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Date of Birth:
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Date of Last Appointment:
Medication #1
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Medication #2
Medication #3
Address Information
Delivery Method
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