• Medication Request

  • ABOUT YOU

  •  / /
  • MEDICATIONS

    List the name of each medication to be refilled. Your physician will verify medication names and quantities before they are processed.
  • PHARMACY

  • PAYMENT

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          1 Week
          $100
            
          2 Weeks
          $200
            
          4 Weeks
          $350
            
        • AGREE TO TERMS
          By clicking the button below I am agreeing to all terms and conditions listed above and also those items listed in my Patient Recovery Contract. I am authorizing Applegate Recovery to charge my card for the selected amount.

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