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Items in RED are required to be completed for your prescription(s) to be filled.

When you submit your order, payment information, including your credit card number, will be sent to our in-house FAX machine via a secure site.

 

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Important Notice

When you submit your order, personal information will be sent to our fax machine via a secure site. While we believe this to be a safe process, we cannot guarantee your privacy against malicious intent. If this is a concern to you, print this page, complete it and fax it to us in the traditional manner. Our fax number is: 734-821-8001. You may also call us at 734-821-8000.

 

 

Have questions? Send us an email anytime.