Saffa Compunding Pharmacy

This form is for current SaffaRx patients to order prescription refills. If you would like to transfer your prescription to SaffaRx Pharmacy, please contact a customer service representative at 1-888-222-2956 or customer_service@saffarx.com.

To order refills simply fill out the form below and click 'Submit Refill'. For help filling out this form, go to the help page.

Medications help
Enter your 6 digit Rx number(s) in the box(es) below. DO NOT include the 'C' on controlled substances.

Rx Numbers

Qty

Rx Numbers

Qty

Rx Numbers

Qty

First Name (as it appears on the label)	df	First Name (as it appears on the label)

Last Name (as it appear on the label)		Date of Birth (mm/dd/yy)
		(example: 05/21/45)
E-mail		Phone

Shipping Method help
FedEx 2nd Day		FedEx Overnight
Payment Method help
Charge credit card on file at SaffaRx ending with last 4 digits:
Charge a new credit card
VISA		Name on card:
MasterCard		Card number:
American Express		Expiration:

Special Instructions: