Refill Order Form

 E-mail orders are downloaded each morning and among the 1st filled each day.
Use this form to order prescription refills only.  To order a prescription not previously filled at The Prescription Shop, please Contact Us . All prescription only medications must have authorized refills remaining before they can be filled.

You can also e-mail your refill request to refills@rxshop.net .  Make sure to include your name, address and phone number as well as the prescription you wish to have refilled.  Unless otherwise specified, we will assume you want to pick up the prescription at The Prescription Shop. Thank You.

* denotes required information        (address & birth date is required ONLY if you are requesting mail or delivery service.)

   

 Full Name*

 

Email*
 Address

 City,ST,zip

 

 

Phone
 Birth Date

Refill Orders

Prescription Number

Name of Drug

Prescription Number Name of Drug
Prescription Number Name of Drug
Prescription Number Name of Drug
Prescription Number Name of Drug
Prescription Number Name of Drug

Payment Information

Cash or Check Existing Store Charge

Delivery Method

I will pick up the order at The Prescription Shop 
Please Deliver to My Home
First Class Mail
Priority Mail ($3.85 Additional)

Special Instructions / Comments  

Include any change in quantity of above refill requests, also you may include any additional non-prescription items you would like to receive with your order, or any other special instructions.

    

Privacy is our utmost concern at the Prescription shop.  So, in accordance with the Office for Civil Rights and HIPPA we have posted our policies on protecting your private information.  If you have any questions on how we protect your records please read our privacy statement or if you have questions about the Office for Civil Rights and HIPPA click here.  If you have not already, please singe our NOTICE OF PRIVACY PRACTICES "NOPP" next time you are in the pharmacy.  If you are unable to receive a NOPP in person we will send you the information (ask for the NOPP in the comments area) .

By using this email form you affirm you are at least 18 years of age, have read the NOPP, and have or will complete* the NOPP Form when you receive your medicine.

*One NOPP form for every patient must be completed (YOU ONLY A REQUIRED TO FILE THE NOPP FORM OUT ONCE.)

Read NOPP here

 

Jonathan/Randy  Newberry.
Copyright © 2003 [The Prescription Shop]. All rights reserved.
Revised: 04/01/05.