Please feel free to print this form and fax this question to 212-571-7465. Please make sure as much of the form is filled out in order for us to process your question as quickly as possible. If you prefer to E-mail the request please click below. Please allow time for your doctor to review your records. If this is an emergency please contact 911 or proceed to the nearest emergency room. Thank you.

Full Name:

Conatct Phone Number:

E-Mail Address: Today's Date:

Date of Birth:

Primary Physician at NY Downtown Medical Associates:

My Current Medications:

I Am Allergic to the Following Medications:

MY QUESTION (please limit to less than 50 words):