Prescription Order Form

Fairview Pharmacy currently accepts refill and transfer prescriptions online.
Please take a moment to fill out the form below.
For transfer prescriptions, your Doctor will be contacted.
Thank you

Prescription Policy
(*Indicates Required Contact Information)
Name on Prescription :
 *
Transfer
Refill
Choose One:
Address:
 *
City:
 *
State:
Zip Code:
Email:
 *
Day Time Phone:
 *
Home Phone:

Prescription Counter: (Please fill out carefully)*
How would you like to receive your prescription? (please choose one)
Pickup at store
Delivery (charges may occur)
 
Has your insurance changed? (please choose one)
Yes (please fax a copy of your new insurance card to 631.474.7871)
No
 

List your prescriptions, one per field. If another prescription is needed, click the "[add another prescription]" link.

Drug Name: *
Refill/Transfer Rx Number: *
Refills Remaining:
Doctor's Name: *
Doctor's Phone: *
Other Information:



4747 - 10 Nesconset Hwy., Port Jefferson Station 11776
(Located in the Port Jefferson Commons)

Member of the Link Long Island Business to Business Directory