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Rex Employee Rx Refill

* First Name:
* Last Name:
* Phone #:
* Email Address:
          Please enter the prescription number(s) from your prescription label (see sample below)

* Prescription #1:
 
Prescription #2:
 
Prescription #3:
 
Prescription #4:
 
Prescription #5:
 
Prescription #6:
 
Prescription #7:
 
Prescription #8:
 
* Would you like the pharmacy to contact your doctor
   if your prescription needs authorization?

            Yes         No