Step 2 of 3

Please enter your name and prescription number(s) below and select Next.

Background Information

A last name is required to verify prescription refill.
First Name
* Last Name

Prescription Number(s)

Please enter the prescription number as it appears on the prescription’s label (e.g. 1234567-89). Select “Next” after filling in the prescription number.
To add another prescription for refill, select Add Another Prescription. You can enter the 1 S. Park Clinic Pharmacy prescription.
* Prescription 1

Preferred Pick Up Time

* Delivery Method

* Preferred Date
Preferred Time
* First Name
* Last Name
* Address 1
Address 2
* City
* State
* Zip