Refill Form

All fields must be completed unless otherwise noted.
 1. Enter your name:
First Name Middle Name
Last Name
 2. Enter your shipping and contact information:
Zip Code
Phone (Home)
Phone (Work) (optional)
Phone (Cell) (optional)
Fax (optional)
Email (optional)
 3. Enter additional shipping preferences:
Please provide any other shipping information. If you wish to have your order combined with a family member to save on shipping, please note here. (optional)
 4. Enter the medications you would like to order:
Please list all medications you are currently taking and the conditions for which they have been prescribed (if applicable). State a quantity for each drug you wish to order.

  Drug Name


  Directions for use


How long have you been taking this drug?   Quantity   requested   Medical condition this drug is used to treat
  Example Drug   12mg   1 tablet a day   8 months   90 pills   Thyroid
Note:  It is generally cheaper to get a 90-day supply. You will get 1 delivery charge instead of 3 and you will receive the benefit of volume discounts on most medications.

To minimize waiting time, please ask your physician to write the prescription for a 3-month supply plus 3 refills. Your initial order for each prescription will be delivered within 14 days in most cases. Refills should be delivered in approximately 10 days.
 5. Read our return policy:
All sales are final. Be sure you order accurately to prevent problems. The law states:
"A pharmacist shall not accept for return to inventory any drug that has been previously dispensed"
Pharmaceutical Act Section 23(1) Return Medication (1)
I have read and understand the information above: Yes No
 6. (If changed since your last order) Enter Credit Card Information:
Cardholder's Name
Credit Card Type    
Credit Card Number
For Mastercard only, please enter three-digit security code from back of card.  Example: xxxxxx  xxx
Expiration date: Month Year
Billing Address:
If different than shipping address