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

  • Contact Us

    NOTE: This is to contact our corporate office. If you’re interested in contacting an individual QuickRx pharmacy, please visit our Locations Page or you can Give Us a Call at (212) 249-8202.