Submit Your Refills

There are 2 ways to request a refill of your medication(s):

1. VIA PHONE: Make sure you have the following information on the drug you want refilled and ask the operator to transfer you to the refill department.

a) Medication Name
b) Dosage
c) Quantities

2. VIA ONLINE: Simply fill out the form below and click on submit to process your refill request. Please contact us after 24 to 48 hours to confirm that we have received your request.

PERSONAL INFO
FIRST NAME		LAST NAME
PLEASE SPECIFY THE ADDRESS THE REFILL(S) SHOULD BE SHIPPED TO
STREET ADDRESS		CITY
STATE	Alabama Alaska Arizona Arkansas California Colorado Connecticut D.C. Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming	COUNTRY	United States
ZIP CODE		PHONE	-
E-MAIL		FAX	-
MEDICATION(S)YOU WANT REFILLED
MEDICATION 1		DOSAGE		QUANTITY
MEDICATION 2		DOSAGE		QUANTITY
MEDICATION 3		DOSAGE		QUANTITY
MEDICATION 4		DOSAGE		QUANTITY
MEDICATION 5		DOSAGE		QUANTITY
SPECIAL INSTRUCTIONS
NOTE: ORDERS WILL BE BILLED TO YOUR CREDIT CARD ALREADY ON FILE.           IF THERE HAS BEEN A CHANGE ON YOUR CREDIT CARD INFORMATION,           PLEASE CONTACT US WITH YOUR REFILL REQUEST AT 1 866 412 6262