Pharmacy prescription refill request

Complete form and click submit request button to send refill request to the selected pharmacy.

Attention Specialty Pharmacy Patients: This form should NOT be used to submit Specialty Pharmacy refill requests. Please contact Specialty Pharmacy at 844-730-5913 (toll-free) or 859-218-5413 to refill your prescriptions.

*Required information
Please provide contact information *

First name
Last name (Your last name as it appears on the prescription label)
Phone
Email (example: janedoe@gmail.com)

Please provide date of birth*

Year
Month
Day

Please select a pharmacy location*






Please select delivery method*



Please provide the Rx# for each refill request *

(example: 507896521; please do NOT enter drug names or any letters)
1)
2)
3)
4)
5)
6)
7)
8)
9)
10)

If you don’t know your prescription numbers, please put the drug names here.
Additional time will be required to refill the prescription.

Drug Names


Additional information

University of Kentucky Notice of Privacy Practices

 I have read and understand the University of Kentucky Notice of Privacy Practices. *
If the delivery method is PICKUP and the refill is AVAILABLE for pickup, please allow at least 4 hours before
picking up a refill that has been requested online.


We ask for your name and e-mail address so that we can contact you about your refills, if necessary.
Your e-mail address will be kept private and will not be sold or added to any mailing lists.