Life Extension Rx - Express Refill

Prescription Information

Enter the prescription number(s) and the last name on the prescription. Be sure to enter it exactly as it appears on prescription label. Refills are charged to the credit card on your account. To change your payment option, please call 1-877-877-9700.


	Prescription Number:	Patient's Last Name:
1
2
3
4
5
6

Additional Information

Enter a phone number, including area code, so our pharmacist can contact you if there is a problem with this order.

	Phone Number:
	(Example: xxx-xxx-xxxx)

	Would you like to:
Pick up your prescription Have your prescription mailed to you

	Would you like the pharmacy to contact your doctor if your prescription needs authorization?
Yes No