Martin Avenue Pharmacy, Inc. -- Prescriptions

To Complete Your Prescription Refill Order

(If order is sent by Fax, Phone, or Internet, you must also send the original doctor's prescription by mail.)


Visa		Mastercard		Discover

We have the ability to ship your products within the United States via FedEx, UPS, or Priority Mail. Prices are subject to change without notice, and shipping & handling is not included.

ALL PRESCRIPTION MEDICATIONS MUST HAVE THE
ORIGINAL DOCTOR'S PRESCRIPTION ATTACHED TO THE ORDER FORM!

Note: Questions marked with an asterisk (*) are required.

(If you do not know the answer to a required question, simply state that you don't know.)

Personal Information (use shipping address if refill is being delivered):

* Full Name:
* Home Phone:
* Work Phone:
* E-mail:
* Date of Birth (mm/dd/yy):

* Street Address:
* City:
* State:
* Zip Code:
* Country:

Payment Method:

* Name on Card:
* Credit Card Type:

* Credit Card Number:
* Expiration Date (mm/yy):
* CVV Number (on back of card):

Medication:

	* Name of medication you want to refill:	* Prescription #
1.
2.
3.
4.

* How would you like to receive your refill?

Pick-up Delivery

If delivering, please choose a delivery service:

DHL UDS Priority Mail

Many other medications available! Call for Availability!