Refill Request HomeRefill Request Please enable JavaScript in your browser to complete this form.Pharmacy where you filled this last? *- Please select -Canary Pharmacy- MontclairCanary Pharmacy- Garden GroveName *FirstLastEmail *EmailConfirm EmailPhone NumberPlease enter your full phone number (no dashes)Enter your prescription number and/or name of the medication *Please provide Rx number(s) and name of your medication(s) you want to transferBy providing your phone number and email address, you authorize us to contact you in connection with pharmacy services, health care and your account via text or live and autodialed calls at the phone number provided above. Your consent is not a condition of purchase or receipt of services and may be revoked at any time. Your carrier’s message and data rates apply. *I consentSubmit