Please fill out the following form so we can process your prescription refill request. Once approved by your doctor, your prescription will be phoned in to your pharmacy within 24 hours.

If you have not been to Tribeca Skin Center within the last 12 months, you will need to call the office for an appointment at 212-334-3774 during normal business hours.

This form is for prescription refill request only. If you have any other questions, please call or email us.

* Required fields First Name* Last Name* Date of Birth* (mm/dd/yyyy) ( / / ) Your Phone Number* (10 digits) Email Pharmacy Phone Number* (10 digits) Name of Medication(s)* (seperate by comas if there are multiple medications you are requesting)