New Prescription Form

Please fill out the form below to submit a copy of your prescription. ORIGINAL PRESCRIPTION from the doctor will be required at the time of pickup for verification by the Pharmacist.

Last Name :

First Name :

Telephone :

Email :

Allergies :

Message :

Upload Picture :

Upload Picture :

Terms and Conditions
By filling out a new prescription submission form, you consent to allowing a pharmacist access to your personal health information. Furthermore, you agree to allow the pharmacist to disclose all prescription and personal health information to physician(s) and drug plans in order to maintain the standard of care when necessary.

ID may be requested upon pickup if a third party is picking up a refill on behalf of the patient.The pharmacy will give you a call once your prescription is ready .

In the case of a technical failure, Lifeline Pharmacy cannot be held liable for delayed or lost requests.