Rebecca J. Kurth, M.D. Internal Medicine 212-230-1081 Deborah P. Jones, M.D.
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Online request form.

4 Dr Kurth with patient
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UPDATE!
As of April 2016, NY State health law now mandates that every controlled substance prescription (e.g. for severe pain or sleep) be prescribed online through our electronic health record system, and reported to a state agency at the time the prescription is written. This can only be done during routine office hours without exception. Any patient on a controlled substance MUST BE EVALUATED IN OFFICE on a regular basis to determine the necessity of continuing on these medications and to assess for side effects or signs of habituation or addiction. If you have any further questions or concerns, please feel free to contact the office.
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For established patients only: please complete this form to the best of your knowledge. This form is for routine prescriptions only. For antibiotics, pain relievers and controlled medication, please call or fax the office. All prescriptions must be electronically prescribed, as per NYS law.

Name:
Date of Birth:
Phone:
E-mail:
     
How many prescriptions would you like to refill?
NOTE: Electronic prescription transmittals requested here on a business day may take up to 24 hours to be processed and received at your pharmacy. Please call us if you need something urgently refilled before then.
   
Prescription #1 Details
Name of medication:
Amount & Dosage
(Ex: 5mg, 5mcg)
Directions:
Number of pills needed:
Refill Amount:
   
Pharmacy information:
Name of Pharmacy
Phone number to Pharmacy
If you don’t have the phone number, please provide location or other information: (please be as specific as possible)
Pharmacy ID Number

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Rebecca J. Kurth, MD, FACP, PC, 800A Fifth Avenue Suite 401, New York, NY 10065, Phone: 212-230-1081, Fax: 212-230-1359
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