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

* Required Fields

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

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What Our Patients Are Saying

View All Testimonials

"I cannot say enough about Dr. Krochak. He is a highly skilled surgeon, who is compassionate, caring ...

Eric Blasich

Procedure

Shoulder Labral Repair

Performed By

Ryan Krochak, M.D.
"I chose Orlin & Cohen for their extensive field in orthopedics and their participation in my healthcare ...

Matt Dunseith

Procedure

Elbow Surgery

Performed By

Eric P. Keefer, M.D.
"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.

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

"I cannot say enough about Dr. Krochak. He is a highly skilled surgeon, who is compassionate, caring ...

Eric Blasich

"I chose Orlin & Cohen for their extensive field in orthopedics and their participation in my healthcare ...

Matt Dunseith

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

Misha Chowdhury

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