Refill Request - Infuserve America

Patient Information

Name

Date of Birth (MM/DD/YY)

Phone/Mobile

Credit Card on File (Last 4 Digits)

Expiration (MM/YY)

Enter Rx Numbers

Prescriptions

Shipping Details

Email

Address Line 1

City

State

Zip Code

Shipping Method

Radio Field

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

Radio Field

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

By completing this form, 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