Refills

To order by Phone 24 hours a day call (269) 327-0033 or 800-689-1823.
Leave a message on our 24-hour voice mail system. When phoning your refill in please have your prescription number available and let us know when you would like to pick up your prescription.

To order by FAX 24 hours a day dial (269) 327-2709.
Patients may fax in refill requests via fax. Please provide in writing the information requested below.

Please fill out the form below to request a refill of your current prescription or supplements.

First Name:
Last Name:
Date of Birth: / /
Address:
City:
State:
Zip:
Daytime Phone: ( )
Email:
Prescriptions:  
1. Prescription Number: Qty:
2. Prescription Number: Qty:
3. Prescription Number: Qty:
4. Prescription Number: Qty:
5. Prescription Number: Qty:
   
Supplements:  
1. Supplement: Strength: Qty:
2. Supplement: Strength: Qty:
3. Supplement: Strength: Qty:
4. Supplement: Strength: Qty:
5. Supplement: Strength: Qty:
   
Shipping: Do you require pick up or shipping?
 
PICK UP
Date picking up: / /
Time: : A.M. P.M.
SHIPPING
Date needed by: / /
Time: : A.M. P.M.

Is your credit card on file with us? YES NO

Comments:
 
1256 East Centre Street • Portage, MI 49002 • 800-689-1823 • FAX: 269-327-2709