RX Refill: Ship to an Arizona address

 

Use this form to request a prescription refill you want shipped by mail to your Arizona address. All fields marked with an asterisk (*) are required.

Name *
Name
Address *
Address
Phone *
Phone
Date of Birth *
Date of Birth
Enter up to five prescription refills and then scroll to the bottom to send
PRESCRIPTION REFILL 1
PRESCRIPTION REFILL 2
PRESCRIPTION REFILL 3
PRESCRIPTION REFILL 4
PRESCRIPTION REFILL 5
SHIPPING
Choose your shipping method *