Refill your prescription via email Fill out all the fields in this form and we will be in touch when the prescription can be picked up.First and Last Name *Date of Birth *Email Address *Used for refill confirmationPhone *Prescriptions to fill:Please use the Rx number to refill. One prescription per line.Pick up or deliveryPick upDeliveryPickup datePickup timeHour-120102030405060708091011Minute-000102030405060708091011121314151617181920212223242526272829303132333435363738394041424344454647484950515253545556575859AMPMSpecial instructions for the driverSend RequestPlease do not fill in this field. Text us You can also text us with your refill request. Send a text message to 306-961-0177