Prescription Refill

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Step 2 of 3 - Enter Prescription Information

Pharmacy Selected

East Towne Pharmacy | Change Pharmacy
* = Required

Contact Information
* First Name		Required
* Last Name		Required
* E-mail Address		RequiredInvalid E-mail
* Confirm E-mail Address		Invalid E-mailRequired
* Phone Number	(xxx)xxx-xxxx	Required
Alternate Phone Number
Prescription Numbers
* 1		Required
2
3
4
5
	Select this button if you have more than five prescriptions to refill. Then enter the additional prescription numbers in the fields provided.
Delivery Information
* Delivery Method	Mail-out Pick-up Delivery	Required
Enter the date and time you would like to pick up your prescription. Prescriptions customarily require one business days to be filled.
* Ready Date		RequiredInvalid (mm/dd/yyyy)
	You must chose a date after 11/22/2009
* Ready Time		Required
Enter the date you would like your prescription delivered. Prescriptions customarily require two business days (48 hours) for delivery and are dropped off Mondays-Fridays between 9am and 5pm. Then enter the address to which you want the prescription delivered below.
* Date Needed By		RequiredInvalid (mm/dd/yyyy)
	You must chose a date after 11/23/2009
Please call your pharmacy to discuss payment options for your prescription order. Enter the date you would like your prescription delivered. Prescriptions customarily require five business days when mailed. Then enter the address to which you want the prescription mailed below.
* Date Needed By		RequiredInvalid (mm/dd/yyyy)
	You must chose a date after 11/26/2009
Delivery Address
* First Name		Required
* Last Name		Required
* Address 1		Required
Address 2
* City		Required
State		Required
* Zip		Required
Comments

Provide all requested information in the available fields. Fields with an asterisk (*) are required. When all information is complete and accurate, select the Process Order button.

East Towne Pharmacy
4122 East Towne Blvd.
Madison, WI 53704
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608-242-6862
Hours: 9am-7pm, Monday-Friday; 9am-5pm, Saturday and Sunday

Prescription Refill

Step 2 of 3 - Enter Prescription Information

Pharmacy Selected

Contact Information

Prescription Numbers

Delivery Information

Delivery Address