PATIENT REFILL ORDER

Please fill in all the relevant details below. Your prescription will be available after 4pm on the next business day. If this is not convenient, please call us on 704 856 2579 to discuss your requirements.;

YOUR DETAILS FIRST NAME LAST NAME EMAIL	PATIENT DETAILS   PATIENT NAME (IF DIFFERENT) DATE OF BIRTH ADDRESS
Please add up to 20 Prescription refill numbers - Please note: these precsrioptions must have been filled at our pharmacy, and must have at least one remaining refill available.         Additional Comments:
Please prove you are a human, and not a computer, by adding the seven digit code into the box as displayed below