• Online Refills
• Online Transfers
• Compounding
• Carolina Apothecary

To refill prescription(s) online, simply complete the Refill Request form below and click submit.

* Indicates a required field.

First Name:* 

Last Name:* 

Date of Birth:* (mm/dd/yyyy)

Prescription# or Name:

1.* 

6.

2.

7.

3.

8.

4.

9.

5.

10.

Delivery Method:* Pick Up Delivery

Pick Up Time:*  9:00am - 11:00am 11:00am - 1:00pm 1:00pm - 3:00pm 3:00pm - 5:00pm 5:00pm - 7:00pm

Pick-up Date

< February 2012 >
Sun	Mon	Tue	Wed	Thu	Fri	Sat
29	30	31	1	2	3	4
5	6	7	8	9	10	11
12	13	14	15	16	17	18
19	20	21	22	23	24	25
26	27	28	29	1	2	3
4	5	6	7	8	9	10

Phone Number:* 

Email Address:

Address:*  (only required for delivery)

City:*

State:*

Zip:*

Please include any comments about your prescription refill

Comments: We respect your email privacy and promise to never sell, barter, share or rent your email address to any unauthorized third party.

Copyright 2011 Belmont Pharmacy
105 Professional Dr. Reidsville, NC 27320
(336) 342-4221