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RX Request Order Form
please fill out this form to start an online order
6
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1
What would you like to do?
*
This field is required.
New Medication
Existing Medication Refill
Both New medication and Existing Refill
My prescription is with another pharmacy
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2
Are you a new patient or an existing patient
New patient
Existing patient
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3
What is your current pharmacy's name and adress?
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4
Delivery or pickup in store?
*
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Delivery
Pick up
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5
What is your shipping adress?
*
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6
Upload Your Prescription
*
This field is required.
Drag and drop files here
Select files to upload
Max. file size
: 10.6MB
Browse Files
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7
RX number(s) for refill
*
This field is required.
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8
Date of Birth?
*
This field is required.
(MM-DD-YYYY)
-
Month
Day
Year
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9
Do you have any allergies?
Yes
No
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10
Which allergies do you have?
*
This field is required.
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11
What is your health card number
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12
Benefits or insurance information? (optional)
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13
What is your home address?
*
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14
Full Patient name
*
This field is required.
First Name
Last Name
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15
Patient Email
*
This field is required.
example@example.com
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