Refill

Patient Information

First Name*
Last Name*
Date of Birth*
Phone*
Credit Card on File (Last 4 Digits)*
Expiration Date*

Enter Rx Numbers

Prescription #1
Prescription #2
Prescription #3

Shipping Details

Email*
Address*
Address 2
City*
State*
Zip*
Shipping Method *
Ground Shipping3 Day Shipping2 Day ShippingOvernight ShippingPatient Pickup
Signature Confirmation *
Add signatureWaive 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, AXE Pharmacy will not be held financially responsible for your order if the package is lost or stolen.

Additional Notes


*I acknowledge all of the information provided above is correct and I authorize AXE Pharmacy to process my refill and charge my credit card.

*Please allow at least 1 to 2 business days for your refill request to be processed.