Refill A Prescription

Refill A Prescription

Please complete the information below to refill your prescription. IMH Pharmacy staff will contact you if there are any issues with processing your prescription refill request.

Number of Prescriptions:
Prescription #1
Prescription Number:
Medication Name:
Prescription #2
Prescription Number:
Medication Name:
Prescription #3
Prescription Number:
Medication Name:
Prescription #4
Prescription Number:
Medication Name:
Prescription #5
Prescription Number:
Medication Name:
Prescription #6
Prescription Number:
Medication Name:
Prescription #7
Prescription Number:
Medication Name:
Prescription #8
Prescription Number:
Medication Name:
Prescription #9
Prescription Number:
Medication Name:
Prescription #10
Prescription Number:
Medication Name:
Prescription #11
Prescription Number:
Medication Name:
Prescription #12
Prescription Number:
Medication Name:
Prescription #13
Prescription Number:
Medication Name:
Prescription #14
Prescription Number:
Medication Name:
Prescription #15
Prescription Number:
Medication Name:
Prescription #16
Prescription Number:
Medication Name:
Prescription #17
Prescription Number:
Medication Name:
Prescription #18
Prescription Number:
Medication Name:
Prescription #19
Prescription Number:
Medication Name:
Prescription #20
Prescription Number:
Medication Name:
First Name:
Last Name:
Phone Number:
Pick-up or Delivery: