Ascend Pharmacy – Refill Form

Patient Information
First Name*
Last Name*
Date of Birth*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.
Email
example@example.com
Prescription Information
Rx Number(s) - Skip this field if unavailable
Do you have any allergy changes since your last prescription?*

YesNo
If yes, please explain:
Payment & Delivery
Card Number
Use Card on File for Payment? (The price for your refill will be the same as your initial prescription)

Yes, use my previous payment method on file
Expiration Date
Security Code
Zip Code
Delivery Address*
Address for medication delivery

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Automatic Refills
Ascend is excited to offer an automatic refill program for patients who are interested. If you would like to enroll in our automatic refill program, you will automatically receive your refill prescriptions without having to complete this form each time.
Would you like to enroll in automatic refills for the remainder of your refills for this prescription?*

YesNo
Notes to Pharmacy
Authorization/Consent
By submitting this form, I authorize Ascend Pharmacy to fill my refill prescription and to charge the payment method indicated*

I Agree
Should be Empty:

Patient Information