Refill | Solutions Pharmacy Inc | Compounding Pharmacy

Today's Date?*

Name*

Prefix First Middle Last Suffix

Prescription holder's date of birth*

Your Address*

Street Address City State ZIP Code

Phone*

Doctors Name on Refill #1*

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*

“ UPS prices & delivery vary by zip code. Please call the pharmacy for exact shipping costs.”

Payment Type*

I 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

Comments

NOTICE: 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.

CAPTCHA

Comments

This field is for validation purposes and should be left unchanged.

Rx Refill

RX Refill