Refill

Medication Refill Request*

$
45

• 
  Must be an existing patient
• 
  Must be 18 yrs old
• 
  Last telemedicine appointment was less than 6 months ago

$45

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Name *

First

Last

Date of Birth *

MM/DD/YYYY

Email *

Email

Confirm Email

Telephone *

Telephone

Complete Address *

Street, Number, City, State, Zip

Name Telephone Date

Pharmacy *

Pharmacy complete Information

Any comments or message?

Submit

*After submitting your request you will be redirected to the payment site.