
				Tel: 310-375-0655 Fax: 310-375-7255

PRESCRIPTION REFILL FORM

Please fill out all fields and click on Send Refill Information to have your refill processed. You may enter up to five separate refill numbers on this form.
Note: all required fields are indicated by :*

First Name.*

Last Name:*

Phone # (ie 1234567890):*

Email:*

Address:

Address 2:

Sorry, we cannot deliver to PO Boxes

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Zip Code:

Important Prescription Information:

Please note, if you are out of refills, or your prescription has expired, we must contact your physician for authorization. This may delay your order.
For refills on compounded medications, please allow a 48 hour (two weekdays) turn around time for completion of your order.
For orders being delivered by UPS, please enter your shipping address above. No P.O. boxes please.

First Refill Number:

Second Refill Number:

Third Refill Number:

Fourth Refill Number:

Fifth Refill Number:

Pick up or Shipping Method:

If you are in need of any OTC Products/Nutritional Supplements, please list them in the spaces below.

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Free Chair Massage Every Tuesday
No strings attached! Just stop the Remedy Pharm on a Tuesday and get a 15 minute chair massage on us. more info>>

Rent our Community Room for your next event!
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Green With Tiffany
Weekly Video Series
In this episode Tiffany gives tips on how to save power.