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Refill Request

Clay Discount Pharmacy

First Name

Email Address

Last Name

Date of Birth

Are you a patient of Clay Discount Pharmacy? * Required

Yes

No

Are you requesting all medications be filled (including medicaiton refills) or just specific medications? If you have new prescriptions please let us know!

Initials

Today's Date

I declare that the info I’ve provided is accurate & complete

I accept terms & conditions

Thanks for submitting!

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