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 offices across Long Island are open for in-person visits with new protocols for immediate, personalized care in the safest possible environment.

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What Our Patients Are Saying

View All Testimonials

"I first used Dr. Keefer in 1998 for a torn rotator cuff. He had been recommended by my internist, Dr. ...

Sondra Blum

Procedure

Rotator Cuff Surgery and Hip Surgery

Performed By

Eric P. Keefer, M.D.
"My first visit to Orlin & Cohen was to see Dr. Garroway after injuring my right shoulder. He was ...

Gary Riesel

Procedure

Shoulder Surgery, Physical Therapy

Performed By

Eric Price, M.D.,Robert Y. Garroway, M.D.
"I came to Orlin & Cohen after a car accident 5 1/2 years ago that left me with multiple herniated ...

Laurie Jackson

Procedure

Pain Management

Performed By

Alfred F. Faust, M.D.,Daniel Yadegar, M.D.

Use form below for prescription refills.

Prescription #1

Prescription #2

Pharmacy information

Our offices across Long Island are open for in-person visits with new protocols for immediate, personalized care in the safest possible environment.

What Our Patients Are Saying

"I first used Dr. Keefer in 1998 for a torn rotator cuff. He had been recommended by my internist, Dr. ...

Sondra Blum

"My first visit to Orlin & Cohen was to see Dr. Garroway after injuring my right shoulder. He was ...

Gary Riesel

"I came to Orlin & Cohen after a car accident 5 1/2 years ago that left me with multiple herniated ...

Laurie Jackson

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