Online Prescription Refill Order Form

To refill existing prescriptions you must fillout the form completely:
 
  1. Complete this form (required information is marked with *)
  2. Confirm Identity Information (REQUIRED)
  3. Confirm Contact information (REQUIRED) 
  4. Confirm all prescription information
  5. Submit form 
For Questions Please Call:  Levelland  806-894-7842  Lamesa   806-872-3069 Big Spring 432-517-4557
 

 
Patient Example of Insurance Card
Please select how you would like to receive your prescription(s)... *
 Pickup at LevellandPickup at LamesaHave shipped to your address
you must have at least one item
Payment options: *
Prescription #, Drug Name & Strength (click the +sign to add another prescription) *