More than 6 Rx's

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Use this form if you want to fill more than 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 7-12 drugs to refill , if you have less than 7, 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.

Demographic Information

My Demographic Information is already on file. Yes No *

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

My Pharmacy Account Number is: (Look on Previous Bill)

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

Comments and other requests:

If the 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. All of the information asked for below can be found on the bottle's label.

Copy your prescription number from the last bottle of the medicine you want refilled medicine; then put that number into the last box.

Original Prescription was:

Drug Name	Rx Number

Press the "Submit" Button below to submit this form to us and you are finished.

You are Here: More than 6 Prescriptions >> Pharmacy >> Home | Site Map

Use this form if you want to fill more than 6 Prescriptions

Comments and other requests:

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

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04/08/2006