REFILL REQUEST FORM

Please verify that your prescription has valid refills remaining. If you have no refills, please contact your doctor for additional refills. New prescriptions must be brought to the pharmacy or phoned in by your physician’s office.

First Name

      
Last Name

      
Telephone Number

   - -    

Refill Numbers

#1       #2       #3       #4

(6 digit # located directly above your name on the label.)
Special Requests or Comments
    

Prescriptions may be picked up at Sand Run Pharmacy Monday through Friday 9am-7pm and Saturday 9am-5pm (closed on major holidays). If this is not convenient for you, local delivery and mail services are available at no charge to you. We deliver in the afternoons to our local area Monday through Saturday and we ship by Priority Mail to anywhere in the United States.

  
Pick Up          Delivery          Mail
 
     
 
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