Webb's Family Pharmacy Refill Request Form

 

Instructions;

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To place your express order on-line complete the four simple steps below. 

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Use the "Tab" key or mouse to navigate around the page. 

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Click on "Send Refill Request" button at the bottom of the page when your are ready to enter your order. 

 

Step 1: Tell us your name and contact information:

Name

E-mail

 

Telephone

(xxx-xxx-xxxx)

 

Step 2: Choose your Pharmacy Location

          Rochester    Akron

 

Step 3: Enter your refill information

 

       Prescription Number(s)           Drug Name (optional)

  1

  2

  3  

  4  

  5

  6

 

Step 4: Delivery Options

  In-Store Pickup

  Local Delivery

  Mail to this address

 

  Would your like the pharmacy to contact your Doctor if your prescription needs authorization

  Yes  No

 

Enter additional comments or additional items you want included with your order in the space provided below:

  

                         

Visit our Wellness Center for heath information and to read about our complete line of Quality Nutritional Supplements

 

 

 

Located in Rochester and Akron Indiana

“The Professional Pharmacy with the Hometown Touch...”

 

 

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