Refill | Solutions Pharmacy Inc | Compounding Pharmacy

Today's Date?*

Name*

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Prescription holder's date of birth*

Your Address*

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Doctors Name on Refill #1*

Prefix First Last

Rx Refill #1*

Refill #1 Qty:*

Do you have another RX to refill?*

Yes
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Doctors Name Refill #2

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Rx Refill #2

Rx Refill #2 Qty"

Do you have a 3rd RX to refill?*

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Doctors Name Refill #3

First Last

Rx Refill #3

Rx Refill #3 Qty:

Do you have a 4th RX to refill?*

Yes
No

Doctors Name Refill #4

First Last

Rx Refill #4

Rx Refill #4 Qty:

Select Shipping or Pickup*

“ UPS prices & delivery vary by zip code. Please call the pharmacy for exact shipping costs.”

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I Authorize payment by same means i used to fill my last prescription and or by choice selected above and do hereby declare that the information above is correct by entering my initials in the box to the right.

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Comments

NOTICE: Someone from our pharmacy will contact you by email or a phone call when your prescription has been processed. If you do not hear from anyone by the end of the next business day, please call and speak to one of our pharmacists to verify your order has been received.

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Rx Refill

RX Refill