(607) 798-9356
  
   
 
   

Refill Request



 

Established patients may request refills of thier medications using our on-line form below.

One of our staff members will process your refill following a consultation with your provider. You will be contacted by a staff member within one business day.

We have added this online prescription refill request form for your convenience,  if you are not comfortable providing any of your Personal health information in this format, or require immediate assistance, please call our office at 607-798-9356 and we will be glad to assist you.

Required Information*:

Name*:

Date of Birth*:

Who wrote the prescription you need a refill of?*

Email Address*:

Phone Number 1*: Home Work Cell

Phone Number 2: Home Work Cell

How do you prefer we contact you?

What is the best time to contact you?

Please enter your text message here*.

Please press submit only once, depending on your internet service provider you may experience a 3-5 second delay to process your request.
 
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