Cardiac Specialists - Fairfield, Trumbull, Danbury, Ridgefield

Appoints and RX Refills

Appointment Request

This information is submitted in secure mode so that it cannot be viewed by 3rd parties. Entries in RED are required for this form to process. Please fill it out as completely as possible in order for us be able to more quickly respond to your appointment request.

Prescription Refill Form
First Name
Last Name
Name of person making request (If Different)
Select Doctor
Date of Birth
Month Day Year
Daytime Tel
Area Code Phone Number
Evening Tel
Area Code Phone Number
Email
Medication
Prescription #
Number of Refills
Dosage
How Often?
Pharmacy information  
If you Pharmacy is not listed above please enter it here
If you have any comments or questions regarding this prescription please let us know

 
 
DISCLAIMER:
Prescription refill requests checked daily.
If this is an emergency please contact us directly.
 
Fairfield
1305 Post Road
Fairfield, CT 06824
Tel: 203.292.2000
Fax: 203.255.5212

Map - Directions
Schedule Appointment

Trumbull
999 Silver Lane
Trumbull, CT 06611
Tel: 203.385.1111
Fax: 203.381.7960

Map - Directions
Schedule Appointment

Danbury
25 Germantown Road
Danbury, CT 06810
Tel: 203.794.0090
Fax: 203.830.4614

Map - Directions
Schedule Appointment

Ridgefield
30 Prospect St. Ste 200
Ridgefield, CT 06877
Tel: 203.438.9621
Fax: 203.438.4596

Map - Directions
Schedule Appointment

Milford
831 Boston Post Road
Milford, CT 06460
Tel: 203.283.5200
Fax: 203.283.5195


 
 
© 2006 Cardiac Specialists, P.C. - All rights reserved.