Request a Prescription Refill from RMCC

Request a Prescription Refill from RMCC

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

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.

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

Please provide your specific call back request and/or question(s).*

Send me a copy of my responses

This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.