Ordering a refill is simple, fill out the form below and press the “Submit” button. Your order will be shipped within 24 hours.

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Personal Information

*Name:

*Date of Birth:

*Phone:

*Email:




Prescription Information

*Medication Rx#:

*Days Supply On Hand:

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After you click the submit button you will receive a confirmation email within an hour. If you do not receive an email, please call us immediately at 1-866-437-8040

All information provided will remain STRICTLY CONFIDENTIAL and used only in conjuction with our services. Privacy Policy




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