.:: Request a New Prescription - Haverstraw Pharmacy ::.

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Prescription

Request a New Prescription

1. If your doctor requests that a pharmacist phone him for your new prescription, and has not provided you with a written prescription, please complete the form below. Our pharmacists will use the information you provide to contact your doctor for authorization to fill your prescription. You may have your prescription shipped to you, or you may pick it up at your local Haverstraw pharmacy.

2. Please do not use the form below if your doctor has provided you with a written prescription. Your doctor may not authorize a prescription over the phone if he has already written one out. Instead, please bring the written prescription order to your local Haverstraw pharmacy to be filled if you�d like to pick it up. Or, you can have this prescription shipped to you by mailing us the written prescription from your doctor along with the Printable Haverstraw pharmacy.com Prescription Order Form.

Please Enter Information Here


*Doctor's First Name:
*Doctor's Last Name:
*Doctor's Phone Number:	( )
Drug Name/Strength:
Quantity:
	* required information
Important: It is Haverstraw pharmacy responsibility to provide our patients with high quality, affordable pharmacy services. It is our standard professional practice to substitute generic equivalents for brand name drugs when authorized by your physician, and within the drug product selection guidelines determined by your state. A brand name medication is usually priced higher than its generic equivalent. If your prescriber has allowed for a generic equivalent to be dispensed, a generic equivalent will be dispensed unless you check the following box.
	I do not accept a generic equivalent.
Note: If a brand name drug is dispensed, you may be responsible for a higher copayment and/or the difference between the brand and generic price of each drug.

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