Refill My Prescriptions

Refill My Prescriptions

Complete this HIPAA Secure Form to request refills on current Integrity Compounding Pharmacy prescriptions.
Patient Information
Name

First Name Last Name
Date of Birth

Month Day Year
Date
Email
example@example.com

Prescription Information
RX # 1
Name of Medication
Do you have any refills?

Yes No Unknown
RX # 2
Name of Medication
Do you have any refills?

Yes No Unknown
RX # 3
Name of Medication
Do you have any refills?

Yes No Unknown

Delivery Method
Would you like to ship your prescriptions?

Yes No, I will pick up my medication.

After submitting, our staff will contact you within 24-48 business hours. Please expect longer processing times if your prescription is expired or out of refills.
Should be Empty: