Prescription Refill Request

For Prescription REFILLS Only 1. Your First and Last Name as it appears on Prescription Label: 2. Do we have your Current Prescription Insurance Information? ~ If yes, continue with your order. ~ If no, call us at (561) 746-7499 with your new insurance information. 3. Fill in the 7 digit Prescription Number and Drug Name: #1 #2 #3 #4 #5 #6 4. How would you like to receive your order? Pick Up at Store Deliver To (street address): Mail To (p.o. box/address): Ship UPS/Fed Ex (street address): 5. Date Needed: 6. Method of Payment: Charge Card C.O.D. House Charge 7. Phone number we can call if we have questions:

General Questions & Comments 8. Please type in any questions you have for the Pharmacist: Choose response method: By Email* By Phone *Your Email Address: 10. Have we missed anything you need or would like to know, or that we should know about? Feel free to make comments.