Refill My Prescriptions
Complete this HIPAA Secure Form to request refills on current Integrity Compounding Pharmacy prescriptions.
Patient Information
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number
*
-
Area Code
Phone Number
Email
example@example.com
Relationship to Patient
*
Self
Spouse
Parent
Child
Other
If you are filling this out on behalf of a patient, please list your full name below:
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Next
Prescription Information
RX # 1
Name of Medication
Do you have any refills?
Yes
No
Unknown
RX # 2
Name of Medication
Do you have any refills?
Yes
No
Unknown
RX # 3
Name of Medication
Do you have any refills?
Yes
No
Unknown
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Next
Delivery Method
How would you like to receive your prescription(s)?
*
Ship to my home address
Ship to an alternate address
Pick up at the pharmacy
Other
Shipping Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How would you like to pay?
*
Charge my current card on file
Text me a link to add a new card on file
Call me to pay over the phone
Other
Please provide the last 4 digits of the card you wish to use:
*
How do you prefer to be contacted with the status of your order or questions regarding your prescription(s)?
*
Call
Text
Email
I understand that if my prescription is expired or out of refills, the pharmacy will contact my provider. This may delay the processing time and a new prescription authorization is not guaranteed.
*
I acknowledge and understand
I understand that Integrity Compounding Pharmacy requires payment prior to processing and dispensing prescriptions. My prescription(s) will not be prepared or shipped until payment is received.
*
I acknowledge and understand
I understand that Integrity Compounding Pharmacy will process my prescription(s) as promptly as possible in accordance with our internal workflow and scheduling. If I require my prescription processed on a specific day or need it urgently, I am responsible for contacting the pharmacy directly to make those arrangements.
*
I acknowledge and understand
I understand that my prescription(s) may require a signature upon delivery. The pharmacy will notify me if a signature is required and when I should expect to be home to sign for it.
*
I acknowledge and understand
I understand that the pharmacy will notify me if my prescription(s) requires refrigeration or freezing. I will be notified of the scheduled ship date and it is my responsibility to ensure I am available to receive the shipment and properly store the medication upon delivery.
*
I acknowledge and understand
Submit
Should be Empty: