* Required Information
Who is this prescription for?
Last Name
*
First Name
*
Phone Number
*
RX REFILL NUMBERS
1
*
2
3
4
5
ADD MORE PRESCRIPTIONS
OVER THE COUNTER ITEM
Name
Qty
1
2
3
4
5
PICK UP OR DELIVERY?
Pickup
Delivery
Would you like us to notify you when your prescription(s) are ready?
Please select.
No, thanks
Yes, via phone
By submitting this form you agree to the terms of the
Privacy Policy
.
Submit