Request Prescription Refills

Please complete the secure form below and press submit. If there is a problem with your prescription refill request or we require more information from you, we will contact you by phone.

All requests will be processed within 24 – 48 hours during regular business hours, Monday – Friday, 8:30 am – 5:00 pm, excluding holidays. If you require an immediate refill or have a question, please contact our office.

Please complete the following information in its entirety.

First Name * Required
Last Name * Required
Date of Birth - must be mm/dd/yyyy format * Required
Date Format: MM slash DD slash YYYY
Daytime Phone * Required
Email Address * Required
My Primary Physician is: * Required
I would like to have my prescription * Required
Please Note: Controlled substances cannot be called in. These prescriptions must be mailed or picked up.
Prescription #1
Medication * Required
Dosage (in mgs/mls) * Required
Prescription #2
Medication
Dosage (in mgs/mls)
Frequency
Pharmacy information

Please tell us which pharmacy you would like us to call your prescription into. Please be precise as there are many pharmacies and pharmacy locations.
Pharmacy Name * Required
Pharmacy Address * Required
Street Address City State / Province / Region ZIP / Postal Code
Pharmacy Phone * Required
Pharmacy Fax * Required
Comments

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Our Merrick office now offers immediate, after-hours care.

Weekdays: 5 p.m. – 10 p.m.
Weekends: 9 a.m -5 p.m.
Walk-ins welcome

516.992.4535

Learn More

What Our Patients Are Saying

View All Testimonials

"Dr Krochak was absolutely amazing! When I first met him I could barely walk and now I am pain free. I’m ...

Misha Chowdhury

Procedure

Knee Microfracture and Patella Stabilization

Performed By

Ryan Krochak, M.D.
"Dr. Ticker performed my shoulder surgery re-attaching and repairing torn tendons in both my rotator cuff ...

Ken Hehir

Procedure

Rotator Cuff Surgery, Bicep Surgery

Performed By

Jonathan B. Ticker, M.D.
"When I was injured at work back in 2003, I knew the only place I wanted to go for treatment was Orlin ...

Kenneth Clements

Procedure

Shoulder, Knee, Back

Performed By

Gregory Lieberman, M.D.

Use form below for prescription refills.

Prescription #1

Prescription #2

Pharmacy information

Our Merrick office now offers immediate, after-hours care.

What Our Patients Are Saying

"Dr Krochak was absolutely amazing! When I first met him I could barely walk and now I am pain free. I’m ...

Misha Chowdhury

"Dr. Ticker performed my shoulder surgery re-attaching and repairing torn tendons in both my rotator cuff ...

Ken Hehir

"When I was injured at work back in 2003, I knew the only place I wanted to go for treatment was Orlin ...

Kenneth Clements

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