Demographic Information

    If the demographic information asked for  (your name, address, telephone number, etc.) is already on file in our pharmacy; you need only to fill out the Last Name, First Name, and the contact telephone number.

* Required fields

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 Telephone Number :       (Where we may contact you if needed)
                                                                        (We must have at least one Phone Number)

Business Telephone Number :    (Where we may contact you if needed)
                                                                        (We must have at least one Phone Number)

My Email Address is   : 

Pharmacy Account Number  :    (If you know it.)

I will pick up my medicine     I would like my medicine delivered      *

Comments and other requests:

    If the upper part of this form is not completely filled out where required ( *), we will be unable to honor this request and there will be no medication refill over the Internet. 

    All of the information asked for below can be found on the bottle's label from the last refill.  Each of the boxes for each drug must be filled out (Drug name, Rx Number.) 

    The "RX Number" can be found on the bottle containing the medication that you would like to have refilled

    Go back up to the top of the form, check it, and make sure that everything is correct, then follow the instructions below.

Top

Press the "Submit" button below to submit the form to us

  Click "Reset" to cancel the order/or start over.