Are you refilling or transferring a prescription?
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Refill
Transfer
Name
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First Name
Last Name
Date of Birth
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-
Month
-
Day
Year
Phone Number
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Format: (000) 000-0000.
Email
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Current Pharmacy
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Current Pharmacy's Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
Are you a new patient at Lee's Summit Pharmacy?
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Yes
No
Would you like to transfer all prescriptions or specific ones?
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Transfer all my prescriptions
Transfer specific prescriptions
List the prescription name or Rx number that you would like to fill at Lee's Summit Pharmacy (one per line).
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EZ Open Caps?
Yes
No
Refill maintenance medications each month?
Yes
No
Do you have a drug allergy?
Yes
No
Which are you allergic to?
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Aspirin
Penicillin
Sulfa
Codeine
Quinolones
Cephalosporin
Macrolides
Other
Are you taking any other medications? List one per line, including over-the-counter and herbal.
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List any medical conditions.
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Please verify that you are human
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Should be Empty: