This request form can be used for prescription supplies you intend to pick up or would like to have mailed to you. Please fill in all fields completely.
If a prescription is not picked up or no billing information is given to mail a prescription within a week, orders will be placed back on the shelves. If you did not pick up your refill within a week, but still need the prescription, please fill out this form again.
Incomplete requests will not be filled. If there are any questions, or if we are unable to fill your prescription request, we will contact you at the phone number you provide below. If no contact phone number is listed, we will not fill a prescription in question.
PickUp: Your order will be ready at this time on the NEXT MyAlly Health business day. Please allow at least 24 hours before stopping in to pick up your prescription. If you need a prescription faster, please call Valley Health at 701.775.4251
Mailed: If you would like your prescription mailed to you, please contact MyAlly Health to provide your billing information. Your prescription will not be mailed until this information is provided. There is a $6.00 - $7.00 mailing fee on ALL mailed out refill orders.
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