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Use this form if you want to fill from 4 - 6 Prescriptions

    By using this form, you are able to re-fill your prescriptions over the Internet.  It's easy, just fill out the form below, click on the "Submit" button, and your order will be sent to us.  

    We will check to make sure that you are able to have the re-fill at this time, call you and tell you when the re-fill is ready for you to pick up or for us to deliver.

    We must have ALL of the form filled out in order to handle your prescription over the Internet.

    In order to be able to use this form, your original prescription MUST have been filled previously by one of our stores.  There must be no changes from the original prescription that is on file. If you only need one drug, just fill in the information for one drug, then skip down to the  "Submit"  button and click on it.

    If you really don't want to be here, you can go back to the Home Page.  This page is for 4-6 drugs to refill , if you have more than 6 or less than 4, click below to go to the correct form.

    The following form must be completely filled out with your name address, phone number etc. in order to have your drugs refilled over the Internet.

If the demographic information asked for is already on file; you need only to fill out the Last Name, First Name, and the contact telephone number.

My Demographic Information is already on file.  Yes    No 

Demographic Information

Last Name:     *  First Name:    Middle Initial: 

Address:      May NOT be a Post Office Box

City:        State:      Zip:   

Home Phone Number:       (Where we may contact you if needed)

Business Phone Number:      (Where we may contact you if needed)

My E-mail address is:    

I will pick up my Medicine        I want my Medicine delivered  *

        Comments and other requests:

If this upper part of the form is not completely filled out,  we will be unable to honor this request and there will be no drug re-fill over the Internet.

Drug Number 1 

From Dr.:       Prescription Number:   

Last Refilled: 

Drug Name and Dosage:   

TOP to check form  /  Bottom to "Submit"  form

Drug  Number 2

Original Prescription was: (If from same physician as the Drug above, just check the box; if a different physician, state Name of physician.)

From Dr: (Same as above)               New Physician 

Prescription Number:                 Last Refilled:

Drug Name and Dosage: 

TOP to check form  /  Bottom to "Submit"  form

Drug  Number 3

Original Prescription was: (If from same physician as the Drug above, just check the box; if a different physician, state Name of physician.)

From Dr.: (Same as above)    New Physician:   

Prescription Number:    Last Refilled:

Drug Name and Dosage: 

TOP to check form  /  Bottom to "Submit"  form

Drug Number 4 

Original Prescription was: (If from same physician as the Drug above, just check the box; if a different physician, state Name of physician.)

From Dr.: (Same as above)      New Physician: From Dr.: 

Prescription Number:    Last Refilled:

Drug Name  and Dosage:

TOP to check form  /  Bottom to "Submit"  form

Drug  Number 5

Original Prescription was: (If from same physician as the Drug above, just check the box; if a different physician, state Name of physician.)

From Dr.: (Same as above)    New Physician:  

Prescription Number:    Last Refilled:   

Drug Name  and Dosage:

TOP to check form  /  Bottom to "Submit"  form

Drug  Number 6

Original Prescription was: (If from same physician as the Drug above, just check the box; if a different physician, state Name of physician.)

From Dr.: (Same as above)    New Physician:  

Prescription Number:    Last Refilled:

Drug Name  and Dosage:

Press the  "Submit"  Button below to submit this form to us.

  Click "Reset" to cancel this order and/or start over.

TOP re-check what you have written

   If you have questions, contact us Click here to Email any questions you may have

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06/07/2004