We will process your refill through our online service as follows:

• Online refills received by noon will be filled the same day.
  
  
• Refills received online after 12:00 p.m. will be refilled and ready for pickup the next business day.

Please allow a minimum of 4 hours for your online refill to be processed.

You may also print and fax this form to our office at (765) 966-4362.

If you need immediate assistance please call our office during business hours at (765) 966-2225 or Toll free (800) 532-1186.

Please enter as much information as possible on the form below.

YOUR PRESCRIPTION INFORMATION Patient Name Daytime Phone Your E-Mail Will you pick-up your prescriptions at our pharmacy, or require home delivery? Pick-up Home Delivery Drug Name RX Number Prescription-1 Prescription-2 Prescription-3 Prescription-4 Prescription-5 Prescription-6 Prescription-7 Special instructions or comments: