Please complete the form below to submit a prescription request. Requests are reviewed daily, Monday-Friday. Please allow 48 hours for your request to be processed.

Requests submitted after 5pm on Friday or on Saturday and Sunday will be processed beginning on the following Monday. Controlled substance prescriptions can now be sent electronically to the pharmacy with some exceptions.

If your prescription requires a PRIOR AUTHORIZATION, please be sure to leave the insurance phone number, which can be obtained from your pharmacist. We do not have this information. For emergencies or general questions, please contact our office at (212) 620-0144.


    First Name (required)

    Last Name (required)

    Date of Birth (required)

    Phone Number (required)

    Email Address (required)

    Preferred Mode of Contact (required)

    Your Primary Care Physician (required)

    Medication Name(s) & Dosage (required)

    Pharmacy Name (required)

    Pharmacy Phone Number (required)