Prescription Refills 

  This form should be used when:

Related Pages:
 
  • You want to refill your doctor's prescription that you or your doctor have previously sent to us.
  Purpose:
 
  • To refill your maintenance medication
  • To note any changes to your record such as new allergies, medical conditions, etc.
  • To set up shipping and billing for your refill
Stop This form is NOT for:

  • Renewals of prescriptions you have received before by an online consultation from us.  Click here to renew those prescriptions.

 * Indicates required fields.  Other fields are optional (but greatly appreciated) 

*Patient Name

*email address

*RxPalace Rx#

Separate multiple entries with commas.
*Medicine to refill

*Male or Female?

*Date of Birth

*Medication Allergies

*Current medications 

(Indicate "none" if necessary)

*Medical Conditions or Chronic Diseases

(Indicate "none" if necessary)
Child-Resistant Enclosure

Payment Information:

*Card Type
*Card Number
*CVV2 Click here for CVV2 help
*Card Expiration

Shipping Information:

*Ship to Address
Ship to Address

*Ship to

City, State, Zip
*Delivery Service
Additional Details