Submit Your Refill

Submit your prescription refill details for our team to review. Once received, a member of our staff will verify your information and confirm prescription eligibility before processing.

Patient name

First name*Last name*

Contact & identification

Date of birth*Phone (US)*Email*

Prescriptions (Rx # & medication)

Choose how many prescriptions you are refilling (up to 6). For each row, enter an Rx #, a medication name, or both, only one is required, but both fields cannot be left empty.

How many prescriptions are you requesting?*

Prescription 1

Rx # (optional if medication given)Medication name (optional if Rx # given)

Prescriber (optional)

If you know your prescriber's details, you may add them here. You can still submit the refill without this section.

Prescriber name (optional)Prescriber phone (optional, US)

Fulfillment method

PickupDelivery

Notes

Notes (optional)

Communications & privacy

Choose SMS and/or email, then confirm data processing.

I agree to receive SMS communications from PSC Pharmacy.I agree to receive email communications from PSC Pharmacy.I agree to allow PSC Pharmacy to store and process my personal data.