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Queens Pharmacy
Refill

Send us a new prescription

Take a photo of the paper prescription and we'll start filling it before you arrive. Bring the original with you at pickup, since we need it for our records.

If your doctor faxed or e-sent the prescription to us, you don't need this form. Just use refill or call.

First name is required.

Last name is required.

So we match the right patient file.

Please enter your date of birth.

10 digits, e.g. 519-555-0100

Make sure the whole page is in the shot and readable. We keep the original on file for the pharmacist.

Not for emergencies. Your information is sent securely to the store you chose and used only to handle this request. See our privacy policy.