Clinic Refill Request Form Please enable JavaScript in your browser to complete this form.Clinic Refill Request FormClinic Name *Clinic Phone Number *Email *Person Placing Refill Order *Patient Full Name *RX Number *Drug Name and QTY *Do you have another RX you want to add?YesNoPatient Full NameRX NumberDrug Name and QTYDo you have another RX you want to add?YesNoPatient Full NameRX NumberDrug Name & QTYShipping *UPS 2 Day $28.95 ($15.95 for Ground States)UPS 2 Day $28.95 ($15.95 for Ground States)UPS Next Day $48.95UPS Next Day on Ice $53.95 (TPA)Utah Clinic Shipping $14.95Local Delivery (Local Salt Lake & Davis County Clinics Only) $9.50Priority MI 3-4 Business Days $14.50First Class 7-10 Business Days $6.50For Standard States, orders of $135 or more get 2 Day shipping for free. For ground States, orders $95 or more get 2 Day shipping for free. Utah clinics, orders of $75 or more get free shipping. Local Salt Lake & Davis County Clinics, orders of $35 or more get free delivery.Additional CommentsCredit Card InformationIf applicable please enter all CC informationSubmit
