Westbury Pharmacy Refills
	First Name Last Name
	Phone Email
	Prescriptions for Refill
	RX1: RX2: RX3: RX4: RX5: RX6: RX7: RX8:
	Delivery Method: Pickup (In-Store) Delivery (Local) $3.00 UPS Ground $7.50 UPS Overnight $27.50 UPS Overnight(Saturday Delivery) $37.50
	"Easy Off" Caps?	NO YES
	Pharmacist or Delivery Note:

**NOTICE & DISCLAIMER**
WESTBURYREFILLS.COM DOES NOT ACCEPT PAYPAL
WESTBURYREFILLS.COM DOES NOT ACCEPT INTERNET-BASED PRESCRIPTIONS -- PLEASE DO NOT SUBMIT YOUR INFORMATION IF YOU ARE NOT AN EXISTING/ESTABLISHED Westbury Pharmacy CUSTOMER.

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