Refill Rx

Refill Your Prescription

*DO NOT SEND YOUR CREDIT CARD INFORMATION WITH THIS FORM, PLEASE CALL US INSTEAD: 704.370.6612.

First Name *

Last Name *

Email Address

Phone Number *

RX #

Would you like to add any additional products to your refill request? Check all that apply.

Syringes (10 ct bag) $5.00 ea

Please select the quantity:

Nitric Oxide Booster (60 ct box) $45.00 ea

Please select the quantity:

CBD - (pharmacy will contact you for specifics)

Please select the quantity:

Would you like to fill multiple months for additional savings?

Fill 2 Months for 10% savings

Fill 3 Months for 15% savings

Would you like to sign up for our Auto Refill Program?

Please indicate the day you wish to pick up your Rx OR click on Rx to be Mailed box.

(Please call if you have questions about our delivery area.)

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