Refill Prescription(s)

Please fill out form with as much information as possible. If prescription is needed ASAP, please make a follow-up call to the pharmacy to ensure all of the information was received correctly.

**If you need a prescription transferred from another pharmacy, please fill out the TransferRx form on our website.

First name

Last name

Phone

Mobile

Home

Date of Birth

Month

Day

Year

Rx#

Drug Name and Strength

Day Supply

30

90

Refills left

1+

None, please send request to provider

Unsure (don't have bottle)

When do you need your prescription?

Select all that apply.

Shipping (add $5.00)

Notify me when ready for pickup

Enroll me in mobile updates

Other (see additional information)

Additional Information

If request is for a controlled substance and needed ASAP, please call pharmacy to confirm drug availability and fill date.

Can't pick up?

GENERx Pharmacy - La Porte

Refill Prescription(s)