Associated Neurological Specialties and Sleep Disorders Center

Kyle: (512) 551-0846 Westlake: (512) 458-2600

Please mark that you have read and understand the refill request instructions and guidelines *

I have read and understand the refill request instructions and guidelines

I have NOT read and/or understand the refill request instructions and guidelines

Date of birth *

Home address (if applicable)

Delivery Method *

Clinic pick-up

Deliver to home address

Phone *

Patient Full Name: *

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Medication Name *

Quantity/Frequency/Dosage *

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Medication Refill Request

(Dr. Das's patients only)

Dear Patients:

Please check on the form below that you have read and understand all refill request instructions and guidelines. This must be done prior to submission. If you have any questions feel free to contact your nurse at (512) 458-2600.

Refill Request Instructions/Guidelines:

This request should be submitted when you have 10 days left of your medication. This allows adequate time for your physician to complete your order.
Fill this form out completely and submit, it will be sent directly to your nurse. All required fields must be complete in order to submit your request
Controlled substances will NOT be filled without a revisit every 3 months
Mailing triplicate refills: prepay for three months for $55.00. We will mail the prescription to you. It is every patient's responsibility to submit the refill request every month, even if payment was done prior
All pick-up triplicate refill requests are charged $20.00, this must be paid at the time you pick up the medication at our office
Triplicates are only good for 21 days from the day written, so pay attention to your dates so your prescription doesn't expire
Any patient receiving pain medication/controlled substances at our office may NOT receive them from another healthcare provider
If your prescription is lost or stolen, we will not be able to refill your prescription until the following month
If your prescription is not working for you or if your are experiencing side effects, we will require you send an email update and at your next appointment depending on side effects, your medication can be changed or the dose can be altered.
Cancellation policy: all appointments must be canceled 24 hours in advance to avoid a $25.00 fee