Refill My Prescription

Refill My Prescription

Park Ridge Pharmacy
40 Park Ave , Store #5, Park Ridge, NJ 07656

P: 201-554-2200 I F: 201-554-2300 | Email: contact@parkridgepharmacy.com
For controlled substances (such as Adderall, Xanax, Valium, or any pain medication), please call us directly at (201) 554-2200. Controlled substances cannot be refilled online.
Patient Full Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Patient Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Patient Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Prescription Number (from the pill bottle label)
👆 Look at the label guide above — your Rx# is the yellow highlighted number at the top left of your pill bottle label. Can't find it? Call us: (201) 554-2200
Medication Name
Your medication name and strength are the large bold text in the middle of the label. Can't find it? Call us: (201) 554-2200
Quantity
Prescriber/Doctor Name
Prescription Number (from the pill bottle label) - additional 1
- you can fill up to 4 prescriptions in 1 time
- Medication Name - additional 1
- Prescriber/Doctor Name - additional 1
- Quantity - additional 1
- Prescription Number (from the pill bottle label) - additional 2
- Medication Name - additional 2
- Prescriber/Doctor Name - additional 2
- Quantity - additional 2
- Prescription Number (from the pill bottle label) - additional 3
- Medication Name - additional 3
- Prescriber/Doctor Name - additional 3
- Quantity - additional 3
- Additional Prescriptions
- Strength
- Preferred Pickup Date
  
  MonthDayYear
  Date
- Preferred Pickup Time
- Would you like delivery instead of pickup?
- Delivery Address
  
  Street Address
  
  Street Address Line 2
  CityState / ProvincePostal / Zip Code
- Any Additional Request(s)
- Signature
- HIPAA Consent & Privacy Notice
- NOTICE OF PRIVACY PRACTICES: Park Ridge Pharmacy is committed to protecting your health information. Your personal and health information will only be used to provide pharmacy services and will never be sold or shared without your written consent. You have the right to request access to your records at any time. For questions about your privacy rights, contact us at contact@parkridgepharmacy.com or call (201) 554-2200. Park Ridge Pharmacy — 40 Park Ave, Unit 5, Park Ridge, NJ 07656.
- I have read and understand the HIPAA Notice of Privacy Practices and authorize Park Ridge Pharmacy to use my health information solely for the purpose of providing pharmacy services.
- I confirm that all information provided in this form is accurate and complete to the best of my knowledge.
- Should be Empty:

Refill My Prescription

40 Park Ave , Store #5, Park Ridge, NJ 07656

HIPAA Consent & Privacy Notice