RX4U Refill

1) Pharmacy Information

Select the pharmacy name that this refill is on file with.

Pharmacy:

2) Prescription Information

Enter the prescription number and the last name on the prescription. Be sure to enter name exactly as it appears on prescription label.

Express Refill

	Patient's Last Name:	*Required
	Prescription Number:	*Required

3) Phone Number

Enter a phone number,including area code, so our pharmacist can contact you if there is a problem with this order or additional information is needed from you.

Phone Number: e.g: 251-5551212*Required

Would you like to:

Pickup your prescription

Have your prescription mailed to your residence

Have your prescription delivered

Yes