Refill Request - Infuserve America

Patient Information

Name

Date of Birth

Phone/Mobile

Credit Card on File (Last 4 Digits)

Prescriptions

RX Number	Quantity Needed

Shipping Details

Shipping Email Address

Do you want this email address to be the default email for your orders?

Set this email address as the default email for my orders

Address Line 1

City

State

Zip Code

Shipping Details

Pick Up or Ship to Address

Patient Pick Up

Ship to Address

Date

Shipping Method

USPS- Ground (aka standard) → 7-10 days → 5$ (After May 1st only select medications may use this option due to heat)

USPS- Priority mail → 3-5 days → 10$ (After May 1st only select medications may use this option due to heat)

FedEx- 2-day shipping is 14.68 (Subject to change depending on size of order)

FedEx- 2-day shipping with signature is 23.11 (For controlled medications only)

FedEx- Priority Overnight (Delivered next business day by 10:30am – Price goes by weight)

FedEx- Standard Overnight (Delivery next business day by 5pm for businesses and by 8pm for residential – Price goes by weight)

FedEx- Express saver (Up to 3 days – Price goes by weight)

Acknowledge

I acknowledge that USPS is not insured and will not be replaced at no charge if lost/damaged/stolen.

FedEx is an insured carrier.

For more information on shipping or pricing, please contact Infuserve America at 1 (800) 886-9222

Additional Notes

For any additional supplies required please include the name of the item along with the quantity required for this order.

Radio Field

By completing this form, I acknowledge all of the information provided above is correct and I authorize Infuserve Pharmacy to process my refill and charge my credit card.