Referral Forms

[vc_row full_width=”stretch_row_content_no_spaces” css=”.vc_custom_1590689867793{margin-top: 0px !important;padding-top: 0px !important;padding-bottom: 5px !important;background-color: #8bc53e !important;}”][vc_column css=”.vc_custom_1590689858705{margin-top: 0px !important;margin-bottom: 0px !important;padding-top: 0px !important;padding-bottom: 0px !important;}”][vc_custom_heading text=”ePrescribe and Referral Forms” font_container=”tag:h1|text_align:center|color:%23ffffff” use_theme_fonts=”yes” css=”.vc_custom_1591804077089{margin-right: 5% !important;margin-left: 5% !important;}”][/vc_column][/vc_row][vc_row css=”.vc_custom_1594999079970{margin-top: 1% !important;margin-bottom: 4% !important;}” el_id=”eprescribe” el_class=”eprescribe”][vc_column][vc_toggle title=”” style=”round” color=”black” size=”lg” custom_font_container=”tag:h1|text_align:left|color:%23083c87″ use_custom_heading=”true”]

BROOKLYN:

  • 2720 Mermaid Avenue Brooklyn, NY 11224
    Phone Number: 718-333-2525
  • 1456 Fulton Street Brooklyn, NY 11216
    Phone Number: 718-638-5088
  • 1458 Fulton Street Brooklyn, NY 11216
    Phone Number: 718-221-4860
  • 1047 Surf Avenue Brooklyn, NY 11216
    Phone Number: 718-819-5249

BRONX:

  • 1642 Eastchester Road Bronx, NY 10461
    Phone Number: 347-691-3494

MANHATTAN:

  • 2355 2nd Avenue New York, NY 10035
    Phone Number: 212-426-7151
  • 909 Columbus Avenue New York, NY 10025
    Phone Number: 212-222-6388

UPSTATE NEW YORK:

  • 279 Main Street New Paltz, NY 12561
    Phone Number: 845-295-3335

[/vc_toggle][/vc_column][/vc_row][vc_row css=”.vc_custom_1590958042858{margin-top: 0px !important;margin-bottom: 0px !important;padding-top: 0px !important;padding-bottom: 0px !important;}”][vc_column width=”1/3″ offset=”vc_hidden-md vc_hidden-sm vc_hidden-xs”][vc_cta h2=”Gastroenterology” h2_font_container=”font_size:1.4vw|color:%23ffffff|line_height:0em” txt_align=”center” style=”3d” color=”white” use_custom_fonts_h2=”true” use_custom_fonts_h4=”true” css=”.vc_custom_1610739370175{border-top-width: 4px !important;border-right-width: 4px !important;border-bottom-width: 4px !important;border-left-width: 4px !important;background-color: #083c87 !important;border-left-color: #8bc53e !important;border-left-style: solid !important;border-right-color: #8bc53e !important;border-right-style: solid !important;border-top-color: #8bc53e !important;border-top-style: solid !important;border-bottom-color: #8bc53e !important;border-bottom-style: solid !important;}”] 

Download Referral Form[/vc_cta][/vc_column][vc_column width=”1/3″ offset=”vc_hidden-md vc_hidden-sm vc_hidden-xs”][vc_cta h2=”Infectious Disease” h2_font_container=”font_size:1.4vw|color:%23ffffff|line_height:0em” txt_align=”center” style=”3d” color=”white” use_custom_fonts_h2=”true” use_custom_fonts_h4=”true” css=”.vc_custom_1610739460173{border-top-width: 4px !important;border-right-width: 4px !important;border-bottom-width: 4px !important;border-left-width: 4px !important;background-color: #083c87 !important;border-left-color: #8bc53e !important;border-left-style: solid !important;border-right-color: #8bc53e !important;border-right-style: solid !important;border-top-color: #8bc53e !important;border-top-style: solid !important;border-bottom-color: #8bc53e !important;border-bottom-style: solid !important;}”] 

Download Referral Form[/vc_cta][/vc_column][vc_column width=”1/3″ offset=”vc_hidden-md vc_hidden-sm vc_hidden-xs”][vc_cta h2=”Hepatology” h2_font_container=”font_size:1.4vw|color:%23ffffff|line_height:0em” txt_align=”center” style=”3d” color=”white” use_custom_fonts_h2=”true” use_custom_fonts_h4=”true” css=”.vc_custom_1610739514298{border-top-width: 4px !important;border-right-width: 4px !important;border-bottom-width: 4px !important;border-left-width: 4px !important;background-color: #083c87 !important;border-left-color: #8bc53e !important;border-left-style: solid !important;border-right-color: #8bc53e !important;border-right-style: solid !important;border-top-color: #8bc53e !important;border-top-style: solid !important;border-bottom-color: #8bc53e !important;border-bottom-style: solid !important;}”] 

Download Referral Form[/vc_cta][/vc_column][/vc_row][vc_row css=”.vc_custom_1590958051291{margin-top: 0px !important;margin-bottom: 0px !important;padding-top: 0px !important;padding-bottom: 0px !important;}”][vc_column width=”1/3″ css=”.vc_custom_1590957780771{margin-top: 2% !important;}” offset=”vc_hidden-lg”][vc_cta h2=”Gastroenterology” h2_font_container=”font_size:7vw|color:%23ffffff|line_height:0em” txt_align=”center” style=”3d” color=”white” use_custom_fonts_h2=”true” use_custom_fonts_h4=”true” css=”.vc_custom_1610739381255{border-top-width: 4px !important;border-right-width: 4px !important;border-bottom-width: 4px !important;border-left-width: 4px !important;background-color: #083c87 !important;border-left-color: #8bc53e !important;border-left-style: solid !important;border-right-color: #8bc53e !important;border-right-style: solid !important;border-top-color: #8bc53e !important;border-top-style: solid !important;border-bottom-color: #8bc53e !important;border-bottom-style: solid !important;}”] 

Download Referral Form[/vc_cta][/vc_column][vc_column width=”1/3″ css=”.vc_custom_1590957786555{margin-top: 2% !important;}” offset=”vc_hidden-lg”][vc_cta h2=”Infectious Disease” h2_font_container=”font_size:7vw|color:%23ffffff|line_height:0em” txt_align=”center” style=”3d” color=”white” use_custom_fonts_h2=”true” use_custom_fonts_h4=”true” css=”.vc_custom_1610739474683{border-top-width: 4px !important;border-right-width: 4px !important;border-bottom-width: 4px !important;border-left-width: 4px !important;background-color: #083c87 !important;border-left-color: #8bc53e !important;border-left-style: solid !important;border-right-color: #8bc53e !important;border-right-style: solid !important;border-top-color: #8bc53e !important;border-top-style: solid !important;border-bottom-color: #8bc53e !important;border-bottom-style: solid !important;}”] 

Download Referral Form[/vc_cta][/vc_column][vc_column width=”1/3″ css=”.vc_custom_1590957792744{margin-top: 2% !important;}” offset=”vc_hidden-lg”][vc_cta h2=”Hepatology” h2_font_container=”font_size:7vw|color:%23ffffff|line_height:0em” txt_align=”center” style=”3d” color=”white” use_custom_fonts_h2=”true” use_custom_fonts_h4=”true” css=”.vc_custom_1610739526212{border-top-width: 4px !important;border-right-width: 4px !important;border-bottom-width: 4px !important;border-left-width: 4px !important;background-color: #083c87 !important;border-left-color: #8bc53e !important;border-left-style: solid !important;border-right-color: #8bc53e !important;border-right-style: solid !important;border-top-color: #8bc53e !important;border-top-style: solid !important;border-bottom-color: #8bc53e !important;border-bottom-style: solid !important;}”] 

Download Referral Form[/vc_cta][/vc_column][/vc_row][vc_row css=”.vc_custom_1590958060391{margin-top: 0px !important;margin-bottom: 0px !important;padding-top: 0px !important;padding-bottom: 0px !important;}”][vc_column width=”1/3″ offset=”vc_hidden-md vc_hidden-sm vc_hidden-xs”][vc_cta h2=”Movement Disorder” h2_font_container=”font_size:1.4vw|color:%23ffffff|line_height:0em” txt_align=”center” style=”3d” color=”white” use_custom_fonts_h2=”true” use_custom_fonts_h4=”true” css=”.vc_custom_1610739579355{border-top-width: 4px !important;border-right-width: 4px !important;border-bottom-width: 4px !important;border-left-width: 4px !important;background-color: #083c87 !important;border-left-color: #8bc53e !important;border-left-style: solid !important;border-right-color: #8bc53e !important;border-right-style: solid !important;border-top-color: #8bc53e !important;border-top-style: solid !important;border-bottom-color: #8bc53e !important;border-bottom-style: solid !important;}”] 

Download Referral Form[/vc_cta][/vc_column][vc_column width=”1/3″ offset=”vc_hidden-md vc_hidden-sm vc_hidden-xs”][vc_cta h2=”Neurology” h2_font_container=”font_size:1.4vw|color:%23ffffff|line_height:0em” txt_align=”center” style=”3d” color=”white” use_custom_fonts_h2=”true” use_custom_fonts_h4=”true” css=”.vc_custom_1610739760521{border-top-width: 4px !important;border-right-width: 4px !important;border-bottom-width: 4px !important;border-left-width: 4px !important;background-color: #083c87 !important;border-left-color: #8bc53e !important;border-left-style: solid !important;border-right-color: #8bc53e !important;border-right-style: solid !important;border-top-color: #8bc53e !important;border-top-style: solid !important;border-bottom-color: #8bc53e !important;border-bottom-style: solid !important;}”] 

Download Referral Form[/vc_cta][/vc_column][vc_column width=”1/3″ offset=”vc_hidden-md vc_hidden-sm vc_hidden-xs”][vc_cta h2=”Immunodeficiency” h2_font_container=”font_size:1.4vw|color:%23ffffff|line_height:0em” txt_align=”center” style=”3d” color=”white” use_custom_fonts_h2=”true” use_custom_fonts_h4=”true” css=”.vc_custom_1610739800236{border-top-width: 4px !important;border-right-width: 4px !important;border-bottom-width: 4px !important;border-left-width: 4px !important;background-color: #083c87 !important;border-left-color: #8bc53e !important;border-left-style: solid !important;border-right-color: #8bc53e !important;border-right-style: solid !important;border-top-color: #8bc53e !important;border-top-style: solid !important;border-bottom-color: #8bc53e !important;border-bottom-style: solid !important;}”] 

Download Referral Form[/vc_cta][/vc_column][/vc_row][vc_row css=”.vc_custom_1590958069396{margin-top: 0px !important;margin-bottom: 0px !important;padding-top: 0px !important;padding-bottom: 0px !important;}”][vc_column width=”1/3″ offset=”vc_hidden-lg”][vc_cta h2=”Movement Disorder” h2_font_container=”font_size:7vw|color:%23ffffff|line_height:0em” txt_align=”center” style=”3d” color=”white” use_custom_fonts_h2=”true” use_custom_fonts_h4=”true” css=”.vc_custom_1610739567614{border-top-width: 4px !important;border-right-width: 4px !important;border-bottom-width: 4px !important;border-left-width: 4px !important;background-color: #083c87 !important;border-left-color: #8bc53e !important;border-left-style: solid !important;border-right-color: #8bc53e !important;border-right-style: solid !important;border-top-color: #8bc53e !important;border-top-style: solid !important;border-bottom-color: #8bc53e !important;border-bottom-style: solid !important;}”] 

Download Referral Form[/vc_cta][/vc_column][vc_column width=”1/3″ offset=”vc_hidden-lg”][vc_cta h2=”Neurology” h2_font_container=”font_size:7vw|color:%23ffffff|line_height:0em” txt_align=”center” style=”3d” color=”white” use_custom_fonts_h2=”true” use_custom_fonts_h4=”true” css=”.vc_custom_1610739769659{border-top-width: 4px !important;border-right-width: 4px !important;border-bottom-width: 4px !important;border-left-width: 4px !important;background-color: #083c87 !important;border-left-color: #8bc53e !important;border-left-style: solid !important;border-right-color: #8bc53e !important;border-right-style: solid !important;border-top-color: #8bc53e !important;border-top-style: solid !important;border-bottom-color: #8bc53e !important;border-bottom-style: solid !important;}”] 

Download Referral Form[/vc_cta][/vc_column][vc_column width=”1/3″ offset=”vc_hidden-lg”][vc_cta h2=”Immunodeficiency” h2_font_container=”font_size:7vw|color:%23ffffff|line_height:0em” txt_align=”center” style=”3d” color=”white” use_custom_fonts_h2=”true” use_custom_fonts_h4=”true” css=”.vc_custom_1610739812770{border-top-width: 4px !important;border-right-width: 4px !important;border-bottom-width: 4px !important;border-left-width: 4px !important;background-color: #083c87 !important;border-left-color: #8bc53e !important;border-left-style: solid !important;border-right-color: #8bc53e !important;border-right-style: solid !important;border-top-color: #8bc53e !important;border-top-style: solid !important;border-bottom-color: #8bc53e !important;border-bottom-style: solid !important;}”] 

Download Referral Form[/vc_cta][/vc_column][/vc_row][vc_row css=”.vc_custom_1590958084988{margin-top: 0px !important;margin-bottom: 0px !important;padding-top: 0px !important;padding-bottom: 0px !important;}”][vc_column width=”1/3″ offset=”vc_hidden-md vc_hidden-sm vc_hidden-xs”][vc_cta h2=”Oncology” h2_font_container=”font_size:1.4vw|color:%23ffffff|line_height:0″ txt_align=”center” style=”3d” color=”white” use_custom_fonts_h2=”true” use_custom_fonts_h4=”true” css=”.vc_custom_1610739988284{border-top-width: 4px !important;border-right-width: 4px !important;border-bottom-width: 4px !important;border-left-width: 4px !important;background-color: #083c87 !important;border-left-color: #8bc53e !important;border-left-style: solid !important;border-right-color: #8bc53e !important;border-right-style: solid !important;border-top-color: #8bc53e !important;border-top-style: solid !important;border-bottom-color: #8bc53e !important;border-bottom-style: solid !important;}”] 

Download Referral Form[/vc_cta][/vc_column][vc_column width=”1/3″ offset=”vc_hidden-md vc_hidden-sm vc_hidden-xs”][vc_cta h2=”Rheumatology” h2_font_container=”font_size:1.4vw|color:%23ffffff|line_height:0em” txt_align=”center” style=”3d” color=”white” use_custom_fonts_h2=”true” use_custom_fonts_h4=”true” css=”.vc_custom_1610740051119{border-top-width: 4px !important;border-right-width: 4px !important;border-bottom-width: 4px !important;border-left-width: 4px !important;background-color: #083c87 !important;border-left-color: #8bc53e !important;border-left-style: solid !important;border-right-color: #8bc53e !important;border-right-style: solid !important;border-top-color: #8bc53e !important;border-top-style: solid !important;border-bottom-color: #8bc53e !important;border-bottom-style: solid !important;}”] 

Download Referral Form[/vc_cta][/vc_column][vc_column width=”1/3″ css=”.vc_custom_1590957889542{margin-bottom: 50px !important;}” offset=”vc_hidden-md vc_hidden-sm vc_hidden-xs”][vc_cta h2=”Dermatology” h2_font_container=”font_size:1.4vw|color:%23ffffff|line_height:0em” txt_align=”center” style=”3d” color=”white” use_custom_fonts_h2=”true” use_custom_fonts_h4=”true” css=”.vc_custom_1610740802509{border-top-width: 4px !important;border-right-width: 4px !important;border-bottom-width: 4px !important;border-left-width: 4px !important;background-color: #083c87 !important;border-left-color: #8bc53e !important;border-left-style: solid !important;border-right-color: #8bc53e !important;border-right-style: solid !important;border-top-color: #8bc53e !important;border-top-style: solid !important;border-bottom-color: #8bc53e !important;border-bottom-style: solid !important;}”] 

Download Referral Form[/vc_cta][/vc_column][/vc_row][vc_row css=”.vc_custom_1590958092826{margin-top: 0px !important;margin-bottom: 0px !important;padding-top: 0px !important;padding-bottom: 0px !important;}”][vc_column width=”1/3″ offset=”vc_hidden-lg”][vc_cta h2=”Oncology” h2_font_container=”font_size:24|color:%23ffffff|line_height:0em” txt_align=”center” style=”3d” color=”white” use_custom_fonts_h2=”true” use_custom_fonts_h4=”true” css=”.vc_custom_1610740006627{border-top-width: 4px !important;border-right-width: 4px !important;border-bottom-width: 4px !important;border-left-width: 4px !important;background-color: #083c87 !important;border-left-color: #8bc53e !important;border-left-style: solid !important;border-right-color: #8bc53e !important;border-right-style: solid !important;border-top-color: #8bc53e !important;border-top-style: solid !important;border-bottom-color: #8bc53e !important;border-bottom-style: solid !important;}”] 

Download Referral Form[/vc_cta][/vc_column][vc_column width=”1/3″ offset=”vc_hidden-lg”][vc_cta h2=”Rheumatology” h2_font_container=”font_size:24|color:%23ffffff|line_height:0em” txt_align=”center” style=”3d” color=”white” use_custom_fonts_h2=”true” use_custom_fonts_h4=”true” css=”.vc_custom_1610740767774{border-top-width: 4px !important;border-right-width: 4px !important;border-bottom-width: 4px !important;border-left-width: 4px !important;background-color: #083c87 !important;border-left-color: #8bc53e !important;border-left-style: solid !important;border-right-color: #8bc53e !important;border-right-style: solid !important;border-top-color: #8bc53e !important;border-top-style: solid !important;border-bottom-color: #8bc53e !important;border-bottom-style: solid !important;}”] 

Download Referral Form[/vc_cta][/vc_column][vc_column width=”1/3″ css=”.vc_custom_1590957907505{margin-bottom: 50px !important;}” offset=”vc_hidden-lg”][vc_cta h2=”Dermatology” h2_font_container=”font_size:24|color:%23ffffff|line_height:0em” txt_align=”center” style=”3d” color=”white” use_custom_fonts_h2=”true” use_custom_fonts_h4=”true” css=”.vc_custom_1610740817217{border-top-width: 4px !important;border-right-width: 4px !important;border-bottom-width: 4px !important;border-left-width: 4px !important;background-color: #083c87 !important;border-left-color: #8bc53e !important;border-left-style: solid !important;border-right-color: #8bc53e !important;border-right-style: solid !important;border-top-color: #8bc53e !important;border-top-style: solid !important;border-bottom-color: #8bc53e !important;border-bottom-style: solid !important;}”] 

Download Referral Form[/vc_cta][/vc_column][/vc_row]

Contact Form (old)

"*" indicates required fields

This field is for validation purposes and should be left unchanged.

Contact

This is to contact our corporate office. If you’re interested in contacting an individual QuickRx pharmacy, please visit our Locations Pages or you can Give Us a Call at the Headquarters (212) 249-8202. If you want immediate specialty pharmacy services please call: (347)-691-3494


Are You a Patient or Provider?