Please feel free to print this form and fax this prescription request to 212-571-7465. Please make sure as much of the form is filled out in order for us to process your request as quickly as possible. If you prefer to E-mail the request please click below. Please allow 1-2 business days from the time of your request for your doctor to review your records and approve the request. Thank you in advance for your patience.

Full Name:
Phone Number:
E-Mail Address:
Today's Date:
Date of Birth:
Medication Allergies:
Primary Physician at NY Downtown Medical Associates:

Name of Pharmacy:
Phone Number of Pharmacy:

Would you like your doctor to call in your prescription?:
Would you like to pick up your prescription at our office?:

Prescrpition #1- Name of Medication:
Prescrpition #1- Dose of Medication:
Prescrpition #1- Amount of Medication:
Prescrpition #1- Fequency in Which You Take Medication:
Precrpition #1- Is This a Refill of a Chronically Used Medication?:

Prescription #2- Name of Medication:
Prescription #2- Dose of Medication:
Prescription #2- Amount of Medication:
Prescription #2- Fequency in Which You Take Medication:
Prescription #2- Is This a Refill of a Chronically Used Medication?:

Prescription #3- Name of Medication:
Prescripition #3- Dose of Medication:
Prescripition #3- Amount of Medication:
Prescripition #3- Fequency in Which You Take Medication:
Prescripition #3- Is This a Refill of a Chronically Used Medication?:

Other Notes: