Patient Information
Name
*
First Name
Last Name
Email
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Prescription Information
List the prescriptions you would like refilled, one per line. Be sure to include the refill number, name of medication, dosage. Example: #3249588, Thyroid, 60 MG
*
Rows
Medication Name
Refill Number
Dosage
Other Dosage,
please specify
1.
30
60
90
Other
2.
30
60
90
Other
3.
30
60
90
Other
4.
30
60
90
Other
5.
30
60
90
Other
6.
30
60
90
Other
7.
30
60
90
Other
8.
30
60
90
Other
9.
30
60
90
Other
10.
30
60
90
Other
How many prescriptions are you refilling today
Number must not equal "0".
Delivery options
*
Pickup
Delivery
Delivery Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Notes for Pharmacist
Comments or special requests.
HDRx is licensed to serve MI, OH, IN, IL, WI, MN, FL.
What state are you in?
*
Please Select
Michigan
Ohio
Indiana
Wisconsin
Minnesota
Florida
Agreement
*
By submitting this form, I agree to receive emails from Healing Dose Compounding Pharmacy
What state are you in?
Submit
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