Fill Prescriptions Online

Patients of Northeast Urogynecology may submit this form to request a prescription refill.

Please complete all of the following information.
All fields marked with an * are required. Your request will not be submitted without filling out the required fields.

Give our office 24-48 hours to refill your perscription.

Feel free to call our office with any questions or concerns.
(518) 438-5538 Monday-Friday 8:30-5:00


*Full Name:
*DOB:
*Day Phone:
Evening Phone:
*Medication Name:
*Strength:
*How Often:
*Pharmacy Name:
*Pharmacy Phone:
*How many doses
do you have left?
Additional Comments:

Northeast Urogynecology - Executive Woods - 5 Palisades Drive - Suite 220 - Albany, New York 12205
Telephone 518.438.5538 - Fax 518.438.6104 - Privacy Policy