Prescription Refill Request
Request a refill from Riley's Pharmacy. We will contact you to confirm. Please do not use this form for emergencies; if this is urgent, call us at 818-244-1195.
Patient name
*
First Name
Last Name
Date of birth
*
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Month
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Day
Year
Date Picker Icon
Phone number
*
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Area Code
Phone Number
Email (optional)
Prescriptions to refill
*
List the Rx number(s) or the medication name(s) you need refilled.
Pickup or delivery?
*
Pickup
Delivery
Anything else? (optional)
Acknowledgment
*
I understand this is a request, not a guarantee of a refill, and the pharmacy will contact me to confirm.
Submit refill request
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