Request Your Prescription Refill

Fill out the form below and our pharmacists will have your medications ready — or delivered to your door. We'll call to confirm within 30 minutes.

Refill Request Form

All fields marked with * are required

Patient Information

First Name *

Last Name *

Date of Birth *

Phone Number *

Email Address

Prescription Details

Medication Name(s) *

Rx Number (if known)

Prescribing Doctor

Delivery Preference

In-Store Pickup Ready same day at our Cudahy location

Free Home Delivery Delivered anywhere in California

Additional Notes

I confirm this refill request is for myself or someone I am authorized to represent.