Request a Prescription Refill from RMCC

If you are looking for an RMCC-dispensed medication refill, please fill out the form below.

For all other prescriptions not filled by RMCC, please contact your pharmacy directly.

Patient's First Name

Patient's Last Name

Patient's Date of Birth

Please type in date of birth: MM/DD/YYYY

Patient's Phone Number

Phone

Medication(s) and Strength(s) Needed OR RX Number(s)

Days Remaining/Next Cycle Date

Desired Shipping Address

Desired Received Shipment Date

Please select a date Tuesday-Saturday.

Due to FedEx staffing issues, some shipments can not be made on weekends and Mondays.

mm/dd/yyyy

Email Address

Please provide your email address if you would like to be sent the FedEx tracking number

Would you like to receive a call back from our Pharmacy team?

Yes

Send me a copy of my responses

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