Amherst Pediatrics: Buffalo, Amherst, Cheektowaga & Tonawanda NY Pediatric Center

Please complete the form fields below and press submit. If there is a problem with your prescription refill request or we require more information from you, we will contact you by phone. You will receive an email when the prescription is filled.

All requests will be processed within 48 hours during regular business hours Monday-Friday 8:30 am-4:30 pm. If you require an immediate refill or have questions, please contact the office at 632-8050.

Patient Information

*First Name:

*Last Name:

*Date of Birth (MM/DD/YYYY):

*Home Phone:

*Daytime Phone:

*Email Address:

*Ordering Provider:

Prescription Information

*How would you like to receive your prescription:

*Medication Name: Please Note: Controlled Substances must be mailed or picked up

*Dosage:

*Frequency:

Pharmacy Information

*Pharmacy Name:

*Pharmacy Address:

*Pharmacy Phone:

*Pharmacy Fax: