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Refill Request Form
Patient Name
Patient name is required and cannot be empty
Phone Number
Phone number is required and cannot be empty.
Email Address
Prescriptions to refill (RX Number)
Rx number is required and cannot be empty.
Payment Method:
To ensure quick processing, we will automatically use the payment method we have on file. You will receive a text confirmation with the last 4 digits of the card used. If there are any issues, we can text you a SECURE payment link to UPDATE OR CHANGE your payment method.
Method of Receipt: (See Patient Benefits)
A tracking # will be texted to you once it leaves our pharmacy:
Additional Instructions:
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