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Prescription Refill Order Form

Please complete this form to submit your refill request if you have an active Xubex account and you have completed payment section of your profile. Please contact customer service at (866) 699-8239 with any questions or comments.

Patient Information

First Name:

Last Name:

Phone:

Email Address:

Prescription Information

Prescription 1:

Prescription 2:

Prescription 3:

Prescription 4:

Prescription 5:

Prescription 6:

Prescription 7:

Prescription 8:

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Activate Account

To activate your online account provide a prescription number along with patient first and last name as stated on the prescription label.
Prescription Number:

Patient First Name:

Patient Last Name:

Patient Email:

Copyright © 2012 Medicine Shoppe Xubex Pharmacy. All Rights Reserved. Privacy Statement
This online pharmacy is obligated to comply fully with the Controlled Substances Act and DEA regulations. As part of this obligation, this online pharmacy has applied for a modified DEA registration authorizing it to operate as an online pharmacy. In addition, this online pharmacy will only dispense a controlled substance to a person who has a valid prescription issued for a legitimate medical purpose based upon a medical relationship with a prescribing practitioner. This includes at least one prior in-person medical evaluation in accordance with section 309 of the Controlled Substances Act (21 U.S.C. 829) or a medical evaluation via telemedicine in accordance with section 102(54) of the Controlled Substances Act (21 U.S.C. 802(54)).
You are encouraged to report negative side effects of prescription drugs to the FDA.
Visit www.fda.gov/medwatch, or call 1-800-FDA-1088.