Rx Refill Request
Reorder early: The Compounder is allergic to emergencies. Are you considering what it would look like to be allergic to emergencies? It's really gross. One person described it as traumatic as looking directly into the sun during an eclipse, but with warts, boils, and oozing lesions. I'm also lying.
Patient Name
*
First Name
Last Name
Cell Phone #
*
Format: (000) 000-0000.
Email
*
example@example.com
Please enter Prescription Number(s).
*
Your RX number is highlighted in yellow on your prescription label. No need to submit multiple forms for multiple prescriptions. Enter them all here!
Please add any Supplements needed or any Special Order Notes here.
You don't have to add any special notes to be considered special. Never forget that.
Do you want to be reminded to refill your medication? We do not fill prescriptions without express written permission. This is only to create a reminder.
Yes, remind me in 30 days
Yes, remind me in 60 days
Yes, remind me in 90 days
Other
Pick Up or Shipping Information
Pick it up in a bag, ship it out in a box.
Pick It Up or Ship It Out?
*
Pick It Up
Ship It Out
Pick Up Options:
*
LOCAL: I will PICK UP, please TEXT when ready.
LOCAL: I will PICK UP, please CALL when ready.
LOCAL: AFTER HOURS PICK UP.
Ship It Options: All shipping methods must provide tracking information and proof of delivery, as per the federal government.
*
SHIP: UPS GROUND RESIDENTIAL ($10.00) **Transit: 1-5 Days** Not including commercial addresses, temperature-sensitive packaging, shipping to a P.O. Box, or expedited shipping.
SHIP: USPS PRIORITY MAIL ($10.00) **Transit: 1-5 Weeks** The US Postal Service will only be used upon request, or when shipping to a P.O. Box.
SHIP: Please contact me to arrange expedited shipping or any other special requests.
Shipping Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
CARD INFO NOTICE:
We changed credit card merchants in 2024. We no longer have your payment info saved. We would love to avoid having to save your credit card info, so the use of an Authorize.net secure payment link is appreciated. To avoid any delay, please text HSA / FSA / FLEX card info to 630-381-7413 or leave it on our voicemail at 630-859-0333.
Payment -
*
Please send me a secure payment link via Authorize.net
Please charge my FSA / HSA / FLEX Card
I will pay via Zelle / Chase Quickpay to thecompounderpharmacy@gmail.com
Other
Please verify that you are also allergic to emergencies and understand that we are not an emergency pharmacy and refill emergencies are just unnecessary stress in an already stressful world full of stress. Please read this twice. Seriously. As my pappy used to say "Your failure to plan is not my emergency." I'm also lying, I never had a pappy.
*
Submit Refill Request. Please click firmly.
Should be Empty: