As with all Prescription Refill Requests, please allow up to two business days for us to process your request. All requests will be e-Prescribed to your pharmacy unless specified below for pick up.
CONTACT YOUR PHARMACY TO CONFIRM YOUR PRESCRIPTION IS READY. If we cannot refill your Prescription, we will contact you; just tell us your preferred method of contact below.
Medication
To avoid errors, it is best to copy the following information directly from your prescription bottle.
Please list all medications separately. List only medications going to the same pharmacy. Only 3 medication may be submitted per form. If you need refills on more that 3 medications, you must submit multiple requests.
Specify by # of days supply you need. Use only if your need is not specified above.
Specify by # of days supply you need. Use only if your need is not specified above.
Specify by # of days supply you need. Use only if your need is not specified above.
Pharmacy
This is the pharmacy to which we will send your prescriptions.
If your Pharmacy is not listed, enter the Name of your Pharmacy here.
We need to know WHICH LOCATION of your pharmacy.<br/>Include your pharmacy's Street Address & City Name
Enter the Phone Number of your pharmacy.
Please allow up to two business days for us to process your request. All requests will be E-Prescribed to your pharmacy unless specified below for pick up.
CONTACT YOUR PHARMACY TO CONFIRM YOUR PRESCRIPTION IS READY.
Note: Controlled Substances can now be e-Prescribed.
Patient Demographic Information
Please provide your first and last name
