When filling out the form, please be sure to fill out the Member Information and Payment Options sections with each order. The Health History section is only required for your first order or as information changes. Please complete the other sections of the form as applicable.

If you need to order new prescriptions, refill current prescriptions, or transfer prescriptions from another pharmacy, please fill out the pdf and either fax (321.434.6105) or mail the printed form to 1350 S. Hickory Street, Melbourne, FL 32901.

Order Form - For New Prescriptions, Refills, or Transferring prescriptions from another pharmacy