Easy Prescription transfers just bring in your prescription bottle or use this form:
1. PATIENT INFORMATION - We need these details for billing, mailing and contact purposes; otherwise they are kept confidential.

First Name:___________________________________________________________________
Last Name:___________________________________________________________________
Date of Birth:  (___/____/____)    
Mailing Address: ______________________________________________________________
City:________________________________________________________________________
State:_______________________________________________________________________
Zip: ______
Phone Number:    (____)- ______-_________
Email Address:___________________@____________
Preferred Contact Method:
(Phone/Email)________________________________
2. CURRENT PHARMACY - Please enter the information of your current pharmacy.

Pharmacy Name:_____________________________________________________________
City:_______________________________________________________________________
State:__________________
Phone Number: (____)-______-___________

3. PRESCRIPTION INFORMATION - Please enter the numbers of ALL prescriptions and names of all medications you would like to refill. 

Prescription Number(s): ________________________________________________________
Name(s) of Medication: ________________________________________________________

     ________________________________________________________​
                           ________________________________________________________​
​                  Fax to: 718-545-1542    or     Email to: AvenueChemist@gmail.com   

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