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Mail Order Prescription Form

If you are a Westlab Pharmacy customer and you wish to get prescriptions refilled, please fill out this form and click on the "SUBMIT" button at the bottom of this page. (If you are not presently a Westlab Pharmacy patient, please complete the "New Patient Registration" form.) You will be billed according to the financial information we have set up for you. If you desire a different arrangement, E-mail, fax or phone us with your request. (Click Here for E-mail and phone numbers)

Name:
E-mail address:
Birthdate (MM/DD/YY)


Refill number or medication name:

Medication Strength

Do you need price quote? No Yes

Refill number or medication name:

Medication Strength
D o you need price quote? No Yes
Refill number or medication name:

Medication Strength
Do you need price quote? No Yes
Refill number or medication name:

Medication Strength
Do you need price quote? No Yes
Refill number or medication name:

Medication Strength
Do you need price quote? No Yes
Please select your choice of delivery
Pick up at the Pharmacy - call when ready
Send UPS standard delivery (3 day)
US Postal Service

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