Stuart Lerner, M.D. - Publicforms

Available Forms

Appointment Request Patient Satisfaction Survey Request for Access Prescription Refill Request

Prescription Refill Request

Note about refill requests:

- Please allow 3 business days for our office to process your request. Please plan ahead for medication refills, as our office is not always able to accommodate same-day requests.

- Prescription refill requests are authorized, pending approval from Dr. Lerner, and our office may contact you to set up an appointment to refill your medication.

You may request a prescription refill in the spaces provided below.

Last Name *

First Name *

Date of Birth *

Phone *

Preferred Pharmacy *

Please provide the pharmacy name and location.

Medication *

Please include name of medication, strength (ex: 40mg, 100mg, etc...) and frequency of use.

Allergies *

If no allergies, write "none".

* Required field