Request Refills

If you are a current customer, use the form below to request refills on your prescription(s).

**If you are a new patient and/or need prescriptions transferred to us, fill out the NEW PATIENT INFO and the TRANSFER MEDICINE forms.**

Be sure to check the bottom of your prescription label to make sure you have refills & the prescription is not expired.

If your medicine does not have refills, we will send a request to your doctor if your doctor accepts refill requests, otherwise you may have to call and request refills.

If you have more than 4 refill numbers, add the rest in the last “notes” field.

Your cell phone number and cell phone carrier are required for us to send you a text message when your prescriptions are ready.

Be sure to click “SUBMIT” after filling in the information.

Name *

First

Last

Birthday *//

Cell Phone Number *

We can text you when your prescriptions are ready.

Cell Phone Carrier *

Prescription Information

Your RX number is a SEVEN digit number on the top left corner of your prescription label.

RX Number 1 *

RX Number 2

RX Number 3

RX Number 4

Any other notes for the pharmacy staff?

If needed, you may add additional RX numbers here.