Refill Request

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Patient Information

First Name

Last Name

Date of Birth

Phone

Credit Card on File (Last 4 Digits)

Expiration Date

Enter Rx Numbers

Prescription #1

Prescription #2

Prescription #3

Shipping Details

Address

Address 2

City

State

Zip

Shipping Method

2 Day Shipping (*15.00)

1 Day Shipping (*33.00)

Patient Pickup (Free)

Cold shipping will default to 1 day shipping at *$41.00
*Ak/HI/PR/Guam price apply: 1 Day - $35.00, 2 Day - $50.00 and Cold - $58.00

Signature Confirmation

Add signature

Waive signature

Any orders that contain a controlled substance or have a total cost that exceeds $100 requires a signature at the time of delivery. If the waive signature option is selected, Empower Pharmacy will not be held financially responsible for your order if the package is lost or stolen.

Additional Notes

I acknowledge all of the information provided above is correct and I authorize Empower Pharmacy to process my refill and charge my credit card.
Most refill orders are processed within 7 business days of the request

Where Do I Find My Rx Number?

Please find your Empower Pharmacy Rx Number on prescription label above your name.