Rx Refill RX Refill Today's Date?* Name* Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Middle Last Suffix Your Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Doctors Name on Refill #1* Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Last Rx Refill #1*Refill #1 Qty:*Do you have another RX to refill?* Yes No Doctors Name Refill #2 Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Middle Last Suffix Rx Refill #2Rx Refill #2 Qty"Do you have a 3rd RX to refill?* Yes No Doctors Name Refill #3 First Last Rx Refill #3Rx Refill #3 Qty:Do you have a 4th RX to refill?* Yes No Doctors Name Refill #4 First Last Rx Refill #4Rx Refill #4 Qty:Select Shipping or Pickup*Pick UpRegular MailUPS GroundUPS Third Day SelectUPS 2nd dayUPS Overnight“ UPS prices & delivery vary by zip code. Please call the pharmacy for exact shipping costs.” Payment Type*I Will Pay When I PickupCredit Card On FileCharge Account on FileI Authorize payment by same means i used to fill my last prescription and or by choice selected above and do hereby declare that the information above is correct by entering my initials in the box to the right. Initial to Authorize:*Email* Enter Email Confirm Email CommentsNOTICE: Someone from our pharmacy will contact you by email or a phone call when your prescription has been processed. If you do not hear from anyone by the end of the next business day, please call and speak to one of our pharmacists to verify your order has been received.