New Customer Prescription Refill Form...

* required information

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.

This form is for new patients only. Current patients may use our KWIK-Rx-Refill Form. New patients please enter your information:

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:

Pharmacy transferring from:
Address
Phone

Pick up
Delivery

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

Address:
City:
Special Instructions:
If pick up is requested, please request a time for pick up * Please key in the access code above for verification. SSL