Please fill out the form below to enroll in our Automatic Refill Program. If you prefer to download and print,
. Please fax back to 281-453-7242 or email to
Select your State
District Of Columbia
Cell Phone #
Daytime Phone #
YES, enroll me in the automatic refill program.
NO, I do not want to participate in the automatic refill program.
Please select the check box below to indicate your acceptance of the terms of this service.
You are authorizing the pharmacy to refill your prescription automatically, at the appropriate time, and to bill your insurance. Your prescriptions will be mailed to you at the above mailing address at no additional charge. You are authorizing the pharmacy to call your physician for a renewal if no valid refills remain on your prescription. It is your responsibility to notify the pharmacy if any of the above contact information changes.
You may cancel automatic refills at any time by contacting the pharmacy at