REFILL REQUEST
Enter up to 8 refills below:
(*Required Field)
*Patient Name:
Refill #1: *RX #: *Name of Drug:
Refill #2: RX #: Name of Drug:
Refill #3: RX #: Name of Drug:
Refill #4: RX #: Name of Drug:
Refill #5: RX #: Name of Drug:
Refill #6: RX #: Name of Drug:
Refill #7: RX #: Name of Drug:
Refill #8: RX #: Name of Drug:
Comment / Additional Items:
Choose one: Pick-up   Delivery *   Mail **
 

 
*Now offering FREE deliveries to Brattleboro, Dummerston, Guilford, Hinsdale, Putney, and Vernon (Except weekends & holidays).
 
**$4.90 to send via USPS Priority Mail