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PRESCRIPTION REQUEST FORM

Complete the prescription request form below.

Medications will only be filled if you are up-to-date with your annual or biannual appointments.

Prescriptions will be filled 48 to 72 hours after receipt of the request. Prescriptions can only be filled during regular business hours 8:00am to 4:30pm, Monday through Friday. We are unable to refill prescriptions on weekends or evenings when the office is closed. Be sure to check with your pharmacy before picking up your prescription.

Patient First Name
Patient Last Name
Email Address
Date of Birth
Daytime Phone Number
Physician
Insurance Carrier
Medication(sa) Requested



Pharmacy
Pharmacy Phone Number
Comments

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739 Irving Avenue - Suite 530 Syracuse, NY 13210 Tel: 315-478-1158 - Fax: 315-478-3014

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