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REquest
Prescription Refill Request
This form is for existing patients only. Please allow 24 business hours for refill processing.

‍If you are experiencing a medical emergency, please dial 911 or go to the nearest emergency room. Do not use this form for urgent medical needs.

This form is HIPAA compliant.
First name
Last Name
Date of birth
Pharmacy Name
Pharmacy Address
Pharmacy Phone number
List all Medication(s), Dosage(s), and days left of each medication
indicate any: changes to your health or medical condition(s), if you have started any new medication(s) or supplement(s), or if you have developed any new allergies to medications.

If not applicable write N/A.
Thank you. The office has recieved your inquiry. Please allow 1 to 2 business days before we contact you.
Oops! Something went wrong while submitting the form. If you are having trouble please call the office (631) 707-3780 or send us an email: office@taneraydinmd.com
Taner Aydin MD · West Islip NY
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500 Montauk Hwy, Ste S, West Islip, NY 11795 · (631) 707-3780

If you are experiencing a mental health emergency, please do not use this website or contact form. Instead, call 911 or go to your nearest emergency room immediately. If you are in emotional distress or thinking about suicide, you can dial 988 to connect with the Suicide & Crisis Lifeline for immediate support.

This office is not able to provide emergency or crisis services.