Cayuga Hematology and Oncology Associates

Prescription Refill

Please complete the information below and press the Submit button. Once your request is submitted, please allow our staff 72 hours to send the prescription directly to your pharmacy, please see below.

WE REQUIRE 3 BUSINESS DAYS ADVANCED NOTICE TO ALLOW FOR SUFFICIENT PROCESSING TIME.

ABOUT SSL CERTIFICATES
Your Name:
Your Date of Birth: / /
Would you like an email confirmation that your request was submitted? Yes    No
If yes, please enter your Email address:
Cayuga Hematology and Oncology Associates is now E-Prescribing. Your prescriptions will be sent electronically to your pharmacy. Narcotic prescriptions and controlled substances will be mailed to your pharmacy. Please provide your pharmacy name and address:
Pharmacy Name:

Prescription 1
Medication Name (as it appears on the bottle):
Strength of medication:
How many pills do you take at a time:
How often do you take them:
How many pills do you take in a 24 hour period?

Prescription 2
Medication Name (as it appears on the bottle):
Strength of medication:
How many pills do you take at a time:
How often do you take them:
How many pills do you take in a 24 hour period?

Prescription 3
Medication Name (as it appears on the bottle):
Strength of medication:
How many pills do you take at a time:
How often do you take them:
How many pills do you take in a 24 hour period?

Prescription 4
Medication Name (as it appears on the bottle):
Strength of medication:
How many pills do you take at a time:
How often do you take them:
How many pills do you take in a 24 hour period?

Are you taking your medications differently than prescribed?
If so, please explain:
Additional Comments:
Internet privacy disclaimer: Although we have taken extensive security precautions, we cannot guarantee absolute privacy of the information submitted through this form. You must understand that there is a risk that in some circumstances, it may be possible for others to see the information submitted through this form while it's transmitted to our computer.
I have read and agreed to the privacy policy of this website.

Our Services | Our Locations | CMC News | Find a Physician | Contact
Cayuga Mecial Center | 101 Dates Drive, Ithaca, NY 14850 | 607-274-4011      Privacy Statement | Disclaimer | Nondiscrimination Notice
©Cayuga Medical Center All Rights Reserved.