Camillus: (315) 487-1541
Liverpool: (315) 652-1070

Prescription Refills Form

For your convenience, use this online form to request prescription refills of non-controlled substances.  Of course, you may also always call your primary office to request prescription refills.

Instructions

Please be sure to complete this entire form to ensure proper processing of your request, then click on the Submit button.

Please fill out completely.

Patient Information

Patient's Name (required)

Patient's Birthdate

Parent's Name

Address

City, State, Zip

Phone Number

Primary Office *REQUIRED
 Camillus Clay/Liverpool

Prescription Information

Name of medication

Dosage

Frequency taken

Quantity of pills

Prescription number

Number of refills

Last prescribed by (Doctor):

Pharmacy Information

Pharmacy

Pharmacy phone number

(Answering this tells the system you aren't a spam robot)

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