Order a Refill

Refill orders are filled for established clients, with a current prescription only.

First Name   Last Name

Date of Birth Phone Email         Address

City State Zip       Prescription Information (Please be as detailed as possible)

You will not be charged until your refill has been authorized by the provider. If you do not receive your refill within 4 days of this order, please contact our office. Payment Info DSHS Take Charge    Credit/Debit Card