| Please fill out all fields and click on Send Refill Information to have your refill processed. You may enter up to five separate refill numbers on this form.
Note: all required fields are indicated by :* |
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First Name: |
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Last Name: |
* |
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Phone Number: |
* (no dashes, ie:1234567890) |
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Email Address: |
* |
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Mailing Address: |
Sorry, we cannot deliver to PO Boxes |
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City: |
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State: |
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Zip Code: |
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Important Prescription Information:
- Please note, if you are out of refills, or your prescription has expired, we must contact your physician for authorization. This may delay your order.
- For refills on compounded medications, please allow a 48 hour (two weekdays) turn around time for completion of your order.
- Some prescription numbers may be preceded by a letter. Enter only the numbers in the fields below.
- For orders being delivered by UPS, please enter your shipping address above. No P.O. boxes please.
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First Refill Number: |
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Second Refill Number: |
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Third Refill Number: |
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Fourth Refill Number: |
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Fifth Refill Number: |
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| Insurance Form Needed : |
check here if you need an insurance form for your compounded medication(s |
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| Delivery Method: |
If shippng UPS, select method —
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If you are in need of any OTC products, please list them in the comments section below.
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Comments: |
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For security purposes, we will call you directly for payment options. |
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