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Prescription Refill Request

Use this form to request refills on your copmpounded prescription(s). Please enter the prescription number(s) you wish us to refill at this time. This number is located on your prescription label (see example to the right).

ALL PRESCRIPTIONS ENTERED MUST MATCH THE LAST NAME AS ENTERED.

We will contact your doctor if your refill(s) need authorization.

Rx Label
Your NAME
Your EMAIL

Your PHONE
Your BIRTH DATE
Your REFILLS

List prescription
numbers and special
instructions in the
box to the right

We use this simple security test to protect your data and ours. Instead of email your information is stored on our domain until we personally download it. Your information is not made available to any email services. Your order cannot be processed until you complete this portion.
Security test. Please identify the pictures: