Online Prescription Refill Form

	Online Prescription Refill
	* Select a Pharmacy:
	* Pickup:
	Requested Pickup Time (allow at least 2 hours for pickup):
	* First Name:
	* Last Name:
	*Date of Birth (MM/DD/YYYY):	//
	* Address:

	* City:
	* Email Address:
	* Phone:
Please note that there are many possible reasons why we might not be able to fill your prescription for the time you requested. Some of these reasons include: if there are no more refills alotted for that prescription, the prescription requested is over one (1) year old, or if we are out of stock. Please make sure to give us a valid phone number and email address where we may reach you in case we encounter any problems with your requested prescription.
	* Prescription Number:
	Help me find the Rx number




	Comments:
		Privacy policy: Louis & Clark will not sell your name or information to any other company or organization. Your prescription information and personal information entered on this form is not stored in any database or shared with anyone other than the Pharmacy filling your prescription.