Refill

We’ll prepare this at Western On-Campus Pharmacy for pickup or delivery.

Pharmacy

Contact email (optional)

First name

Last name

Birthday

Any drug allergy

Phone (optional)

Rx number or drug name

Fulfillment

Refill schedule

One refill now. Switch to a schedule to have the next ones filled when you’re due.

Notes

Payment arranged with your pharmacy

Your pharmacy will confirm any amount due and how to pay when your request is ready.

No card details are collected here. Please do not include card numbers or security codes in notes or photos.

We will review this before it’s filled. I agree to the privacy notice and counselling terms.