Prescription refill request
For your convenience, use this form to fax your request for prescription refills of non-controlled substances.

Of course, you may always call your primary office to request prescription refills.

Instructions
Print this form. Please be sure to fill out all the blanks to ensure proper processing of your request. Fax it to your primary office below.

• Download this pdf form and print it using Adobe Acrobat Reader.

Primary office fax numbers:

Camillus office FAX: (315) 487 - 3485

Liverpool office FAX: (315) 652 - 4679

Please fill out completely

Patient / parent information Patient's name: _________________________________________ Patient's birthday: __________________________________ Parent's name: _________________________________________ Address: _________________________________________ Phone number: _________________________________________ Primary office:    Camillus    Clay

Prescription information

Name of drug: __________________________________________________

Dosage: ___________________________________________________

Frequency taken: ________________________________________________

Quantity of pills: _____________________________________________

Prescription number: ______________________________________________

Number of refills: ____________________________________________

Last prescribed by (Doctor): ________________________________________

Pharmacy information (for non-controlled substances)

Pharmacy: _________________________________________________

Pharmacy phone number: __________________________________________

For controlled Substances
Mail home Pick up at office

Phone numbers:

Camillus office Phone: (315) 487 - 1541	Liverpool office Phone: (315) 652 - 1070
Page last updated: May 24, 2004