Employee RxExpress
 AUPCC Pharmacy Online Refill Form

NOTE: Requests made before 12:00 in the afternoon,  will be delivered that day (or ready that day).
Requests made after 12:00 in the afternoon, it will be ready the following business day.

Tell us how to get in touch with you:

First Name
Last Name
Date of Birth
E-mail
Home Telephone
Campus Telephone
Campus Address
(Room #, Building)

Prescription you wish to refill:

Rx Number
Drug Name/Strength
Quantity Filled

Campus Delivery?

No, I will  Pickup 

Yes,  I want Campus Delivery (Exact change for cash payment)

Payment:

 Comments:

Please review above information before submitting:

   

Copyright © 2005 [AU HSOP]. All rights reserved.
Revised: 08/14/07.