Rx Refill RX Refill Today's Date?* MM slash DD slash YYYY Name* Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Middle Last Suffix Prescription holder's date of birth* MM slash DD slash YYYY Your Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest 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 First Last Suffix Rx Refill #2 Rx Refill #2 Qty" Do you have a 3rd RX to refill?* Yes No Doctors Name Refill #3 First Last Rx Refill #3 Rx Refill #3 Qty: Do you have a 4th RX to refill?* Yes No Doctors Name Refill #4 First Last Rx Refill #4 Rx 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. CAPTCHAPhoneThis field is for validation purposes and should be left unchanged.