Prescription Request

The best way to get your prescription refills is to contact your pharmacy to see if you already have refills available to you. If you do not have refills left, please complete the information below. We will call your prescription in to your pharmacy within 48 hours. Please call your pharmacy prior to picking up your medication to make sure it is ready.
An asterisk * indicates a required field.
*First Name
*Last Name
*Date of Birth
*Prescription Name and milligrams
*How many days supply
*How Often do you
take the medications?




*Doctor
*Is Refill Request
*Pharmacy





*Pharmacy Location or
Phone number:
Your E-mail