Cardiology Associates of Fairfield County

Please provide the following information and your prescription will be called in by our office within 2 working days.

Your Cardiologist:
Your Name:
Your Daytime Phone #:
Your Date of Birth: (mm/dd/yyyy)
Your Pharmacy:
Pharmacy Phone #:
Medication:	Dosage:
Prescription Refill #:
Medication:	Dosage:
Prescription Refill #:
Medication:	Dosage:
Prescription Refill #:
Would you like to pick up a written prescription instead?	Yes No
Is Generic Acceptable?	Yes No
Supply:	30 Day 90 Day
If possible, please have your pharmacy fax a renewal request. Our fax numbers are: Norwalk: 203-845-2162 Stamford: 203-323-1747