Rx Refill

PHONE: 208-922-4400 FAX: 208-922-4499

Copyright 2011, Custom Rx, LLC

COPYRIGHT 2011, CUSTOM RX, LLC

PRESCRIPTION REFILL FORM

PRESCRIPTION NUMBER
or
NAME OF DRUG

NAME

Phone Number with Area Code

I Will Pick Up My Prescription(s)

I Would Like My Prescription(s) Mailed

I Would Like My Prescription(s) Delivered

Mailing Address
Flat $2.00
Shipping Fee

Delivery Address
Free Delivery in Meridian & Kuna
$3.00 Delivery Charge for Surrounding Area

Credit Card Number

Expiration Date

CCV Code

Name on Credit Card

Rest assured that Custom Rx Pharmacy takes all necessary steps to ensure that your private information remains private including a High Level SSL Security Certifcate.

* An SSL Certificate enables encryption of sensitive informatiuon during online
transactions.

* Each SSL contains unique, authenticated informsation about the certificate
owner.

* Every SSL Certificate is issued by a Certificate Authority that verifes the identity
of the certificate owner.

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