RxUSA.com NY Pharmacy    

Toll Free: 800-764-3648

Toll Free Fax: 866-843-4154 or 866-845-4129

Phone: 516-467-2500 Fax: 516-299-4492  

 

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Refill Order Form
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Patient Information:
   Save my below information for next time.
First Name:
Last Name:
Daytime Phone Number: () -
Email Address:   
RxUSA account #:
Payment:
Use my Credit Card Number PPS already has on file
Call me for bank card number
No payment required 
Address:
Same as last time (skip next section) 
New address (complete next section)
New Address Information:
Address:
Address continued:
City:
State:
Zip Code: -
Birth date 
for verification purposes: 


We can not ship unless you accept a form of order confirmation.

e-mail notification is acceptable to release my order
notification to my phone or voice mail is acceptable to release my order
no notification is needed by me, release my order
 

Refill Drugs Requested

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Prescription #: Drug Name/Description:  Quantity:

Do you need a paper order form included with your order? No Yes

Comments:

(Valid phone number or email address required for order confirmation.)

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Security: (enter the characters in the field)



We do not dispense Controlled Substance prescriptions to patients in the following states: Arkansas, California, Hawaii, Idaho, Louisiana, Michigan, Montana, Nebraska, North Carolina, Tennessee and Utah. All prices quoted, and orders shipped, are billed and shipped FOB New York City . No returns may be accepted for drugs and medication, in accordance with Federal and State regulations governing prescription drugs and medications. All prescriptions received by phone, fax, e-mail, or postal mail, from patients, physicians, clinics, hospitals, or other health care professionals are received by our pharmacy in New York State and are subject to being filled under the jurisdiction and laws and regulations of the State of New York and appropriate Federal regulations if applicable. Delivery of your drugs or  medication, regardless of the address you designate, will be construed to have been made in the State of New York by our giving your order to DHL or the United State Postal Service for delivery to you. Your transmission to us of your prescription and request to have your drugs or medication shipped to you at any designated address is an acknowledgement that you have read this notice and agree that New York State and Federal laws and regulations govern and control your prescription order.