Only to be used for regular, refill medication.
The prescription can be picked up on the same day from 12h00 pm.
Your Info
First Name
Last Name
Sex
Male or Female ?
Date Of Birth
Your E-Mail
Your Phone
Prescription #1
Prescription's Name
Dosage
Frequency
Prescription #2
Prescription's Name
Dosage
Frequency
Prescription #3
Prescription's Name
Dosage
Frequency
Prescription #4
Prescription's Name
Dosage
Frequency
Prescription #5
Prescription's Name
Dosage
Frequency
Prescription #6
Prescription's Name
Dosage
Frequency
Prescription #7
Prescription's Name
Dosage
Frequency
Prescription #8
Prescription's Name
Dosage
Frequency
Required Fields
Please enter your First Name
Please enter your Last Name
Please enter your Birth Date
Please enter if you are a Male or Female
Please enter at least your Email or your Phone
Please enter at least one Prescription Frequency
Please enter at least one Prescription Dosage
Please enter at least one Prescription Name
Field