Request a Refill

Please fill in the form below to request a refill. You must have a valid prescription number in order to use this system. Please note that if you use more than one location you will need to make individual requests for refills to the store where the prescription was filled.

You can find your prescription number and store address on the label:

No prescription number? No Problem!

If you don't have a valid prescription number, can't find your number of don't know your number, NO PROBLEM! Please feel free to contact your friendly Fagen pharmacist and they will be more than willing to assist you. The pharmacist will need to verify some personal information when you call to protect your privacy.

All fields in the form below are required.

Patient Last Name:
Date of Birth:
Rx Number:
Pharmacy Location: