Information Update

Main Menu

Online Refills

Be sure to ask about
our delivery service!

AndroidApple

please scan for a link to access our smartphone app

Information Update

Name*	Invalid Input
Street Address	Invalid Input
City	Invalid Input
State	Invalid Input
Zip	Invalid Input

Nickname	Invalid Input
Home Phone	Invalid Input
Mobile Phone	Invalid Input
Work Phone	Invalid Input
Email Address	Invalid Input

Physician	Invalid Input
Gender	MaleFemale Invalid Input
Date of Birth	Invalid Input

Do You Have A Prescription Drug Card? YesNo Invalid Input
If Yes, What is the Cardholder's Name? Invalid Input
What is the ID Number on the Card? Invalid Input
What is the BIN number? Invalid Input
What is the group number? Invalid Input
What is your Relationship to the Cardholder? Invalid Input
Do You Require SAFETY (Childproof) Caps On Your Medicine? YesNo Invalid Input

Known Drug Allergies (Choose All That Apply) No Known Allergies Aspirin or NSAIDS Cephalosporins (Ceclor, Keflex) Codeine, Morphine, Oxycodone Erythromycin, Biaxin, Zithromax Penicillin, Amoxicillin, Ampcillin Sulfa Drugs (Septra, Bactrim) Tetracyclines, Doxycycline Xanthines (Theophyline, Caffeine) Other Pharmaceuticals Invalid Input

Health Conditions Angina Anemia Arthritis Asthma Blood Clotting Disorder Blood Pressure - High Blood Pressure - Low Blood Pressure - Irregular Breast Feeding Cancer Diabetes Heart Disease Kidney Disease Liver Disease Parkinsonism Ulcers, Gerd, Etc. Difficulty Swallowing Colostomy, Urostomy Invalid Input

Other Allergies and Drug Reactions Invalid Input

Other Health Conditions (Not Including Pregnancy) Invalid Input

If You Are Pregnant What Is Your Due Date Invalid Input

List Any Prescription Medications You Currently Take Which Were Not Purchased Through Us Invalid Input

List Any Non-prescription Medications You Are Currently Taking Invalid Input

Validation Code	Refresh Invalid Input