Refill

At Pacific Pharmacy, we have made it easier for you to order your prescription online at the comfort of your own home. Fill in the required fields below and save time!

Requests sent will be responded to during regular business hours. Mon-Fri 9:00AM to 5:00PM. Any requests during the weekends or after hours are not guaranteed a response or action.

"*" indicates required fields

Name*

First Last

Email*

Year of Birth (4 characters)*

Phone*

Prescription Numbers*

Prescription #1

Prescription #2

Prescription #3

Note: Your prescription # can be found on your prescription label. View Sample
Also, if you have more than three (3) prescriptions, please fill out the form a second time.

Select a Location*

15122 72 Avenue

11944 88 Ave

101-8386 120th street

Please Check One*

Delivery

Pick-up

Special Remarks*

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Comments

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Note:

Delivery Time of Your Medication
Medications with prescription refills remaining will be prepared by our staff in a timely manner. Please call the pharmacy to inquire about delivery date. Your pharmacy’s telephone number appears on the medication label.

Pick Up Time of Your Medication
Medications with prescription refills remaining will be prepared by our staff in a timely manner. Please call the pharmacy if you would like to know when your medication will be ready by. Your pharmacy’s telephone number appears on the medication label.

Refills Remaining
Please telephone the pharmacy if you need assistance. The amount of refills remaining appears on the medication label

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