Refills - BRIGHTON RX PHARMACY

SIMPLY text the word rEFILL to 718-332-8428

Fill out the form below with the prescriptions you'd like to REFILL and we'll update you when they are ready.

*Full Name:

*Date of Birth:

Has your address changed?

Yes

Address:

City :

Zip:

State:

Has your insurance changed?

Yes

Insurance Company:

Member ID#

RxBIN (6 digits):

RxPCN:

RxGroup or GRP:

Attach a picture of your prescription label OR you can fill out the info below.

Rx# or Drug:

Would you like to enroll in Auto-Refills?

Yes