Auto-Refill Program

Ready Rx Auto-Refill Program

At Taconic Pharmacy we value your time and realize how busy you are. Sometimes it is hard for you to

remember to refill your prescription. Don't worry, just fill out the form below and become part of our ReadyRx Refill Program. We will automatically refill your prescription for you. We can even deliver it directly to your home if you desire. It is that easy. There is no charge to be part of this program. Just another way Taconic Pharmacy helps you make sure you take your medication on time and get the most benefit from your prescriptions.

Fill out and submit the form below to guarantee you never run out of your prescription again!

Transfer Rx Form

STEP 1: PATIENT INFORMATION

Full Name

Date of Birth

Address

City

State

Zip Code

Phone Number

Email Address

Prescription Insurance Provider

SPACER

STEP 2: PRESCRIPTION INFORMATION

1. Rx Number

2. Rx Number

3. Rx Number

4. Rx Number

5. Rx Number

6. Rx Number

1. Rx Name

2. Rx Name

3. Rx Name

4. Rx Name

5. Rx Name

6. Rx Name

SPACER

STEP 3: ENROLLMENT CONFIRMATION

I am requesting to be enrolled in the Ready Rx Auto-Refill Program. I understand prescriptions are not eligible for the Ready Rx Auto-Refill Program if they: 1) Are controlled substances, 2) Are paid for by Medicare Part B, Worker's Compensation or State Medicaid 3) Or fail to meet all eligible refill requirements.

Opt-In

I AGREE, PLEASE ENROLL ME UPON SUBMISSION.