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Renew A Prescription

CONFIDENTIAL MEDICAL COMMUNICATION
Renew A Prescription should be used to renew a prescription written by your doctor. Your doctor may need to see you in the office before a renewal is written. This form should not be used for URGENT messages OR for refills that have already run out and need to be filled today. Requests received will be responded to within 2 business days.

Please DO NOT USE this form for urgent messages or an emergency. IN AN EMERGENCY, CALL 911 OR GO TO THE NEAREST EMERGENCY ROOM. If you have new symptoms or an urgent question or concern, please call our office.

Please complete all required fields

Patient First Name: *

Patient Last Name: *

Patient E-mail Address:

Patient Date of Birth: *

Daytime Phone:*
--

Alternate Phone:
--

Department:*

Physician:*

Prescription Delivery Options:*

Number of Prescriptions to Fill:*

Your prescription(s) will be called in to the pharmacy indicated on your request within 2 business days.
Pharmacy Name:*

Pharmacy Phone:*
--

Your prescription(s) will be ready within 2 business days. Our office will call you at the number indicated when it is ready for pick up.
Your prescription(s) will be mailed to the address indicated in your request within 2 business days.
Street Address:*

Town/City:*

State:*

Zip:*

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Important Note:

The Stony Brook Medicine University Physicians website is primarily an informational and educational resource. It should not be used in place of medical advice and recommendations you receive from your health care provider. If you have, or suspect that you have a medical problem or condition, please seek the advice of your health care provider.


Stony Brook Medicine University Physicians provides marketing advice and consultation to the clinical Faculty associated with the University Faculty Practice Corporations (UFPCs). It does not provide medical care directly or indirectly nor does it oversee, direct, manage or supervise the medical care provided by any of the individual Practices. The individual Practices are responsible for the medical care each Practice provides to its patients. Please note that the Practices listed below are separate University Faculty Practice Corporations (UFPCs).