Refill Request

Refill Request Form

Hello! Please fill in the form below. Thanks!
Form Name
Name*

PrefixFirst NameLast Name
Date of Birth*

MonthDayYear
Cell Number:*
Please note we will be sending you updates of status and delivery
E-mail
Please enter to receive tracking information for your rx delivery.
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)
Do you want your medication delivered?

YesNo, I'll pick up at your pharmacy
What address would you like your medication(s) delivered to?

Street Address

Street Address Line 2

CityState / 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?*

YesNo
Would you like to set up auto refill?*

YesNo
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
How would you like to pay for your copay?*
Signature (Drag Finger or Mouse to Sign)*

Clear
Date

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

Refill Request Form