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Please fill out the information below to order a refill on a prescription that you filled at one of our Discount Drug Mart pharmacy locations. The request will be processed electronically and will be made available at the store where you originally filled the prescription. We do not at this time have the ability to send your refill order to a different location.

Click Here for Details of Notice Of Privacy Practices.

Please note that all fields with an * are required.

PRESCRIPTION REORDER FORM

*Name

*Address

*City/State

*Zip Code

*Phone No

*Email


PRESCRIPTION INFORMATION:
NEED HELP? Click here for sample label.

*Physician Name:  

*Pharmacy #:         

This is the pharmacy where you first filled this prescription. (The pharmacy number appears on the top of your prescription label.)


*Rx Number(s): (Do not include letters.)

 
 
 
Enter up to 6 Rx Numbers.

(The Rx number appears on the left side of your
prescription label, under the Discount Drug Mart logo.)

Have my order ready to pick up today.**

Have my order ready to pick up tomorrow.**

Restrictions apply click here for details.