Refill Prescription
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Prescription Name/Number
*
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
How would you like to receive your prescription?
Pick up at Designer Drugs Pharmacy
Ship to me
Verify Shipping Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
A member of our team will reach out to you by phone for payment.
If your refill is for an injectable medication, do you need syringes?
*
Yes
No
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Submit
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