To start you Compounded Rx Refill, please fill in the form using the Rx number or if you don’t have the number, the medication name for each. COMPOUNDED PRESCRIPTION RXS ONLY! Who Is This Prescription For?Name* First Last Phone Number*Email Medications NeededEntering Refill Information Enter your refill Rx# below.Rx Number 1: Enter your Rx number from your prescription bottle.Rx Number 2: Pick-Up InformationRefill Availability: 1-4 Days We like to have 48 hrs. notice to prepare your compounded refill before you can pick it up or have it shipped out. Shipping takes 1-3 days depending on our proximity to us. If you need this sooner, please call us to discuss.Pickup, Delivery or Shipping*Please Choose OneI will pick-up at the PharmacyDeliver to MeMail to me (2-3 days to receive)Payment InformationPlease call the pharmacy at (724) 926-2117, M-F 9a-5p to make a payment if needed.Payment Options Bill my Credit Card on File I will call the pharmacy to arrange for payment Would you like us to notify you when your prescriptios are ready?* No, Thank You Yes, via Telephone Yes, via Email Yes, via Text Message (cell # should be in phone Above) Message or Instructions To The PharmacyCaptcha