Patient Name* (last, first) Date of Birth* (mm/dd/yyyy) Email* Select MD* ---DR. SANDHYA GUDAPATIDR. PAROOL PATELOPEYEMI BELLO, PMHNPMedication Name* Dosage* Height* Weight* Pharmacy Name* Pharmacy Street Address Pharmacy City Date of Last Appointment* (mm/dd/yyyy) Date of Next Scheduled Appointment* (mm/dd/yyyy) If you are due for an appointment, please schedule appointment first and then send in RX request.RX refills will be done only if you maintain follow up appointments. Please give us 3 business days (72 hrs.) notice to process this request. Due to DEA regulations, controlled prescriptions will not be transferred to another pharmacy once it has been sent out. You can check with pharmacy first if they have enough in stock. There is a $15 charge for controlled Rx refill. Thanks.