Make sure you include the name of the medication, the dosage (in grams, mgs, or percent), dosage schedule (how many pills you take and how many times a day you take them) and whether you want a 30 or 90 day supply.

• Name:
• Email Address:
  
• Pharmacy Name:
• Pharmacy Location:
  
  

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• Prescription Request:

• 	# of Days30 Days90 Days

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  Remember: NYS controlled substances can not be called in or sent electronically to the pharmacy! For NYS controlled substances, please choose how you would like to receive your prescription.

  Pick UpMail

• Address:

Click submit when all requested medications have been entered.