Refill My Prescriptions

Refill My Prescriptions

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

First NameLast Name
Date of Birth

MonthDayYear
Date
Phone Number

Area CodePhone Number
Email
example@example.com

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

YesNoUnknown
RX # 2
Name of Medication
Do you have any refills?

YesNoUnknown
RX # 3
Name of Medication
Do you have any refills?

YesNoUnknown

Delivery Method
Would you like to ship your prescriptions?

YesNo, I will pick up my medication.Other
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
After submitting, our staff will contact you within 24-48 business hours to go over payment information. Please expect longer processing times if your prescription is expired or out of refills.
Should be Empty: