Please include the PATIENT'S NAME below.
Please note that FedEx will not ship to a P.O. Box, the address needs to be a physical address. FedEx Next Day Air delivery does not include Saturday delivery. Refrigerated items require special shipping.
We accept American Express, Visa, MasterCard and Discover (please call 1-800-227-2627 to provide a credit card number or we will use the card from
your last order).
** When we process this refill we will use the same credit card we used on your previous order. **
Please do NOT include credit card information when completing this Secure Online Refill Form.