Upload Your Prescription

Submit your prescription securely and get your medications delivered to your door

Prescription Upload Form

All information is encrypted and HIPAA compliant

1 Personal Information

First Name *

Please provide your first name.

Last Name *

Please provide your last name.

Email Address *

Please provide a valid email address.

Phone Number *

Please provide a valid phone number.

Date of Birth *

Please provide your date of birth.

Gender

2 Upload Prescription

Accepted File Types: JPG, PNG, PDF (Max 10MB per file)
Requirements: Clear, readable image of the complete prescription

Prescription Files *

Drag & Drop your prescription files here

Please upload at least one prescription file.

Prescription Type *

New Prescription
First time filling this prescription

Refill
Refilling an existing prescription

Please select prescription type.

Additional Information

3 Delivery Information

Street Address *

Please provide your street address.

City *

Please provide your city.

State *

Please select your state.

ZIP Code *

Please provide a valid ZIP code.

Delivery Preference

Standard Delivery (5-7 days)
Free shipping on orders over $50

Express Delivery (2-3 days)
Additional $15.99 shipping fee

4 Review & Submit

Review Your Information

I agree to the Terms & Conditions, Privacy Policy, and Medical Disclaimer *

You must agree to the terms and conditions.

Upload Process

Personal Info Enter your details

Upload Files Submit prescription

Delivery Info Shipping details

Review & Submit Final confirmation

Security & Privacy

256-bit SSL encryption
HIPAA compliant
Private & confidential
Licensed pharmacists

Need Help?

Our support team is here to assist you

Contact Support

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