Open Monday to Friday, 9 AM to 6 PM
Statmeds Pharmacy
Refill

Prescription request

New patient request

Three short steps: about you, your coverage and prescriber, then your medications.

Navy clipboard with a blank form, a pen and a prescription vial on a pharmacy counter
  • A team member calls youDuring business hours, to confirm your details
  • We confirm coverage and costWith your plan, or a cash price quote
  • We fill and deliverOr have it ready for pickup in Hicksville
  • Prefer to call?(516) 900-0636, Monday to Friday, 9 AM to 6 PM

New patient request

Tell us about you, your prescriber and what you need filled. A team member will call to confirm details and coverage.

Your health information is protected. What you send through this form is protected health information under HIPAA. It is sent over an encrypted connection to our pharmacy team and is used and disclosed as described in our Notice of Privacy Practices. Don’t use this form for emergencies or urgent medical questions. Call us at (516) 900-0636 or dial 911.
About you
We’ll call this number about your request. We text only if you opt in below.
Best way to reach you
Coverage
How will you pay?
List any medication allergies, or write “none known.”
Your prescriber
For example: dermatology practice in Garden City.
Medications
Pickup or delivery
How would you like to get your medication?
Delivery instructions, timing, or anything else we should know.
Fields marked * are required.

For prescribers and office staff

E-prescribe to Statmeds Pharmacy, 399 W John St Ste 100, Hicksville, NY 11801. Fax non-controlled prescriptions to (877) 961-1116.

Prescriber information