StarcareRx

Your Name *

Your Email *

Date Of Birth * (EX: MM /DD /YYYY)

Your Phone Number *

Name Of Current Pharmacy *

Phone Number Of Current Pharmacy *

Your Prescription Number Or Medication Name 1 *

Your Prescription Number Or Medication Name 2

Your Prescription Number Or Medication Name 3

Your Prescription Number Or Medication Name 4

Your Prescription Number Or Medication Name 5

Notify me when ready (By checking this box, one of our team members can notify you once the prescription is ready.):

Via Phone

Via Text

Via Email

Would you like to:

Pickup

Deliver (Most deliveries are made between 10am - 2pm on the following day)

Mail (shipping charges may apply)

If you chose text, provide your mobile number:

If picking up, when would you like to pick up your prescription