City Line Family Medicine

301 City Avenue ■ Suite 100 ■ Bala Cynwyd, PA 19004
Phone 610-617-1300 ■ Fax 610-617-0199 ■ Text/Voicemail* 484-429-9141

Prescriptions

  • Use of this web service indicates the user's agreement to be bound by the terms of use and knowledge of disclaimers listed.
  • 24 to 48 hours (1-2 business days) is required to process prescription requests.  If your medication is needed sooner please contact the office at 610-617-1300.
  • Providing incorrect information or omitting information will delay the processing of your prescription request.  Therefore review your information prior to submitting.
  • This service is only available to current, already established, patients of City Line Family Medicine as defined in the "Terms of Use" page.

For mail order prescription requests please select the "Mail Order Rx to be faxed" option for the "Would you like your prescription:" question.

Enter your Full Name:
Date of Birth - mm/dd/yy:
Home Phone # with Area Code: 
Cell Phone # with Area Code: 
Primary Care Physician:
Would you like your prescription:
Pharmacy Name: (Rite Aid, CVS,...)
Pharmacy Phone or Fax# with Area Code: - "Written RX" to pick up
Pharmacy Zip Code:
Name of First Medication Needed:
Dosage or Strength (ex: 10 mg ): 
How do you take this medication? (ex: 1 pill daily): 
How many pills do you need? (ex: 30): 
How many refills?

Optional Fields

Name of Second Medication Needed:
Dosage or Strength:
How do you take this medication:
How many pills do you need?
How many refills?
   
Name of Third Medication Needed:
Dosage or Strength:
How do you take this medication: 
How many pills do you need?
How many refills?

 

Please press the submit button only once. It may take a few moments for submission. 

*depending upon your calling/texting plan, additional charges may apply.