Refill Request

Form Name

Name *

Prefix First Name Last Name

Date of Birth *

Month Day Year

Phone Number: *

Area Code Phone Number

Prescription Number for Refill

Do you have additional prescriptions to refill?

Prescription Number for Refill (2)

Prescription Number for Refill (3)

Prescription Number for Refill (4)

Would you like to update your contact information?

E-mail

Please enter to receive tracking information for your rx delivery.

Cellphone Number:

Area Code Phone Number

Home Phone Number:

Area Code Phone Number

What is your preferred form of contact?

Cellphone Number Home Phone Number Email

Can we send you text messages?

Yes No

Do you want your medication delivered?

Yes No, I'll pick up at your pharmacy

What address would you like your medication(s) delivered to?

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Is the delivery address a doorman building?

Can the package be left with your doorman or at the doorstep/porch if no one is home? *

Yes No

Would you like to set up auto refill? *

Yes No

Refills will be delivered within 2-3 business days. Please note here if you have any specific questions or comments.

Do you want to update your prescription insurance information?

Please Take a Photo of the Front and Back of your Prescription Insurance Card (We will need the RX BIN, PCN, GRP, and ID.)

Front of Prescription (Rx) Insurance Card

Back of Prescription (Rx) Insurance Card

For your convenience, we have several OTC items that we can add on to your prescription delivery. Would you like to see the options?

KN95 Masks (5 Count) $ 25.00

Quantity
Item subtotal: $ 0.00

Cetaphil Gentle Skin Cleanser (4 oz) $ 5.50

Quantity

Cetaphil Intensive Moisturizing Cream (3 oz) $ 6.00

Quantity

Cetaphil Daily Facial Cleanser (4 oz) $ 5.50

Quantity

Cetaphil Moisturizing Lotion (4 oz) $ 6.00

Quantity

Total $ 0.00

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

How would you like to pay for your copay?

Signature (Drag Finger or Mouse to Sign) *

Clear

Date

Thank you! Feel free to text/call us at 212-749-6626 or email us at Hi@ahmarx.com with any questions.