Bay Pharmacy Discount

Refill Online

You do not have to go through the process of waiting in line to have your prescriptions refilled. For your benefit, we offer you the chance to have your medicines refilled online.

Who is this prescription for? (* = Requiered Information )

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Who is this prescription for? (* = Requiered Information )

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* = Requiered Information

Full Name *

Address*

City *

State*

Zip*

How do you prefer to be contacted?

Email Address*

FAX

Phone *

Best time to call *

Preferred Date

Preferred DateCurrent Medical ConditionsDo you take any Food/Vitamin supplements? If so, what?Do you smoke? If yes, how many per day?Exercise (what types and how often)

How well do you sleep?

GoodAverageRestlessPoor

Average hours of sleep per night

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