Prescription refill form

You may enter multiple prescription numbers and/or prescription names, separated with commas.
Name:
Employee badge number:
Date of Birth:
Address:
Allergies:
Prescription Number(s) (if known):
Name of Medication(s) Needed:
Phone Number:
Method of Payment:

Note: In order to use your Laymon Medical Expense Account Credit Card, you must have already stopped by the Medical Mall Pharmacy to set up this service. Otherwise, you will be charged via payroll deduction.