Associated Neurological Specialties and Sleep Disorders Center

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

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