* = Required Information
All communication will be returned within 1 business day. If you do not receive a call/email, please contact us directly.
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
How would you like to receive your prescription.
Pickup
Ship
Would you like to have your order shipped to the address on file and use the same payment information?
Yes
No
Customer Signature
Yes
No
If no, please provide new shipping and payment information in the comment box below.
Your RX Pharmacy will not be responsible for the package and will not replace any lost/stolen/damaged packaged free of charge.
Would you like us to notify you when your prescription(s) are ready?
No, thanks
Yes, via phone
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