Manhattan Office
390 West End Ave #1E
(at 78th Street)
New York, NY 10024
Tel: 212-787-1444
Fax: 212-799-8620

Westchester Office
495 Central Park Ave
Suite #305
Scarsdale, NY 10583
Tel: 914-725-7555
Fax: 914-725-4553

Prescription Renewal Form

Use the convenience of our web site to request a prescription renewal and avoid the telephone call!

Read from existing prescription label
Use this form to renew chronic medications such as medications used for reactive airway disease or ADHD.
Do not use for medications for acute illnesses.
Prescription renewals are processed Monday to Friday only.
Please allow 48 hours for processing - Please always keep track of all medications as to avoid running out!

Please complete the information below:

* Required Information

Today's Date*

Parent First Name*

Parent Last Name*

Child First Name*

Child Last Name*

Date of Birth*

Allergies:*

Weight*

Prescription #: (Check prescription label)*

Medication*

Strength & Form: (e.g., Flovent-44 HFA MDI)*

Directions for Use: (e.g., 2 puffs twice a day)*

Pharmacy Name:*

Pharmacy Phone #: (Include area code)*

Best Contact Number:
(Where you can be reached in person, include area code)*

Email Address:*

For Controlled Substance:

Will pick up

Mail home

For Non-Controlled Medications - Refills Requested?

Yes

Primary Provider:

Office Location: