Prescription Refill Form

NOTE:
You will receive a confirmation email within 2 hours during business hours or by 10:00 a.m.
for overnight/weekend orders. If you do not receive a confirmation email please call
(608) 362-1234.

To insure a delivery time most convenient for you, please request refills at least one day in
advance.

This form is for current patients only. Please complete the following:

Name:     
Email:      
Email:       (confirmation)
Enter your 6 digit prescription number(s) and patient's name.
Rx Number: Name:
Rx Number: Name:
Rx Number: Name:
Rx Number: Name:
Rx Number: Name:
Rx Number: Name:
Pick Up          Requested pick up time:
Delivery          View Delivery Schedule
Would you like us to add any Over-the-counter (OTC) medications or grocery items to your order? If yes, please list. (Click here for list of most popular items.)
Special Instructions: