Heritage Pharmacy : On-Line Refill

Refilling your prescription is a simple process. Just complete the information below and we will refill your prescription as quickly as possible.

	Check this box if your personal information has changed since your last prescription refill.
	Check this box if generic drugs are acceptable.

	* Required fields
* First Name
* Last Name
* Address
Address 2
* City
* State
* Zip Code
Phone Number
Email Address
* Refill Numbers and Comments

Select a Delivery Method
Heritage Pharmacy Mid Dakota Clinic 9th & Rosser
	At the Pharmacy
	Mail Prescription

Heritage Pharmacy Center for Women
	At the Pharmacy
	Mail Prescription
	Drive Up Window

Select a Payment Method
	Pay at the Pharmacy
	Pay with a Credit Card

If you selected Pay with a Credit Card, the following fields are required:
Credit Card Type
Name on Card
Credit Card Number
Credit Card Expiration
Credit Card V Code	V Code is the 3 digit number on the back of your credit card. The V code is located in the signature line or is the last three numbers directly after your credit card number.