NOTE:
In order to insure that your order has been received by Clinic Pharmacy.... Expect a confirmation e-mail within 2 hours during business hours or by 10:30 a.m. for overnight/weekend orders.
If you do not receive a confirmation e-mail...
please call 608-786-2828.

Name:
Address:
City:
State:
Zip:
Phone:
*E-mail:
*E-mail:	(for confirmation)

Enter your prescription number(s) OR drug name and patients name in the following fields:

Rx Name/Number: Patient:
Rx Name/Number: Patient:
Rx Name/Number: Patient:
Rx Name/Number: Patient:
Rx Name/Number: Patient:
Rx Name/Number: Patient:
Rx Name/Number: Patient:

Is this prescription a transfer from a different pharmacy?
If so, please fill out the following fields:

Pick up
Delivery

If delivery is requested, please include your address if it is different from the address above

Address:
City:		West Salem Bangor La Crosse
Special Instructions:
If pick up is requested, please request a time for pick up 9 a.m. to 12 p.m. 12 p.m. to 3 p.m. 3 p.m. to 6 p.m. Tomorrow in 2 days in 3 days in 4 days * Please key in the access code above for verification.      SSL Certificates