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Refill a Prescription

Fill out the information below to refill your resident’s medication(s) through our secure form. By submitting your refill request you are agreeing to United Community Pharmacy’s HIPAA Notice of Privacy Practices. Please note this is for refills only, for new orders contact us directly at 612-259-8275.

Name*
Client First Name* Client Last Name*
Phone Number*
Email Address*
RX Number(s)*
How would you like to get your prescriptions?
- Pick Up
- Delivery
Is the medication needed within 24 hours of this form submission?
- Yes
- No
If you are completing this form on behalf of a client, please provide your name and contact information.
Full Name
Your Phone
Your Email
Additional Comments & Questions
Phone
This field is for validation purposes and should be left unchanged.