Lakeside Pharmacy is happy to offer prescription refill requests from our website. Fill out the appropriate fields below and we'll take it from there. Please allow 24 hours for our FREE DELIVERY service to bring your prescription to you if submitted after our normal store hours. Same day delivery is available in most cases. Prescriptions to be picked up will be ready shortly if submitted during our regular store hours.

Patient's Name:
Patient's Home Phone:
Patient's Work Phone:
Patient's Cell Phone:
Patient's Address:
City, State, Zip:
Email Address:
Patient Date of Birth:
Prescription Drug Insurance:

Please complete the following information for each prescription to be transferred to Lakeside Pharmacy (complete more than one form if necessary):

First Prescription
Pharmacy Name:
Pharmacy Phone Number:
Prescription Number:
Medication Name:
Medication Strength:
Medication Quantity:
Prescribing Physician:

Second Prescription
Pharmacy Name:
Pharmacy Phone Number:
Prescription Number:
Medication Name:
Medication Strength:
Medication Quantity:
Prescribing Physician:

Third Prescription
Pharmacy Name:
Pharmacy Phone Number:
Prescription Number:
Medication Name:
Medication Strength:
Medication Quantity:
Prescribing Physician:

Fourth Prescription
Pharmacy Name:
Pharmacy Phone Number:
Prescription Number:
Medication Name:
Medication Strength:
Medication Quantity:
Prescribing Physician: