Your Prescription

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2 Select Your Pharmacy



Refill Your Prescription


This form is for submitting requests for refills online (up to 10 prescriptions).Please complete all of the information accurately. Please complete this form providing your name, prescription number, and phone number. Without this information your order will not be processed. Your refill will be ready within 12 hours.

All fields marked with * are required


Prescription Numbers or Names: *

If you see this please contact us

Call your doctor for medical advice about side effects.
You may report side effects to the FDA at 1-800-FDA-1088.

Transfer Your Prescription

This form is for submitting requests for prescription transfers from another pharmacy (up to 3 prescriptions). Please complete all of the information accurately. Please complete this form providing your name, phone number, and transferring pharmacy name and number. Without this information your order will not be processed.

All fields marked with * are required


Prescription Numbers or Names: *

If you see this please contact us

Set-up Automatic Prescription Refill

This form is submitting requests for automatic refills. These medications will be automatically filled for you every month. Please complete all of the information accurately. Please complete this form providing your name, prescription number, and phone number. Without this information your order will not be processed. You can also include a note for any questions. Click Submit and your order will be processed.

All fields marked with * are required


Prescription Numbers or Names: *

If you see this please contact us

       

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