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Refill Request

Rx30 RefillRx - Generic Viagra®

RefillRx Mobile App

You can fill out our the refill request form below or use your smart phone to scan the barcode on your bottle using the “RefillRx® Mobile” app found in either Google Play or Apple App Store.

To download the RefillRx® Mobile AppWith your smart phone, scan the QR code to the right to take you the RefillRx App Download page and pick your platform.

Refill Request Form

Who Is This Prescription For?
Name*
First Last
Phone*
Email Address*
Medications Needed
Entering Refill Information
If you don't have the refill # we can look your refill up for you.
Rx Number 1:
Enter your Rx number from your prescription bottle.
ED Rx Medication Type to Refill*
- Generic Viagra® 100mg
- Generic Viagra® 50mg
- Sildenafil 20mg
- Generic Cialis® 20mg.
- Generic Cialis&reg 10mg.
Do You Need Other Rxs Refilled Also?
- Yes
- No
Rx Number 2:
Name of Drug 2:
Rx Number 3:
Name of Drug 3:
Extended Days Supply?
100mg Generic Viagra® Quantity Requested
An Extended Days supply will save you money! Providing you have enough refills left to fulfill, or we will request added refills from your physician if needed.
- #10 for $100
- #20 for $169
- #30 for $209
50mg Generic Viagra® Quantity Requested
An Extended Days supply will save you money! Providing you have enough refills left to fulfill, or we will request added refills from your physician if needed.
- #10 for $100
- #20 for $169
- #30 for $209
20mg Sildenafil Quantity Requested
An Extended Days supply will save you money! Providing you have enough refills left to fulfill, or we will request added refills from your physician if needed.
- #50 for $80
- #100 for $140
- #150 for $180
20mg Generic Cialis® Quantity Requested
- #10 for $99
- #20 fr $169
- #30 for $209
An Extended Days supply will save you money! Providing you have enough refills left to fulfill, or we will request added refills from your physician if needed.
10mg. Generic Cialis® Quantity Requested
- #10 for $99
- #20 for $169
- #30 for $209
An Extended Days supply will save you money! Providing you have enough refills left to fulfill, or we will request added refills from your physician if needed.
Pick-Up Information
Pickup, Delivery or Shipping*
Discount Coupon Code
Enter any Discount Coupon Code you may have and we will verify and honor it when we bill you.
Payment Method
Please indicate how you will pay for this refill.
If you are mailing us a Money Order our address is:

Canandaigua The Medicine Shoppe
66 West Ave.
Canandaigua, NY 14424
Would you like us to notify you when your prescriptions are ready?*
- No, Thank You
- Yes, via Telephone
- Yes, via Text Message (cell # should be in phone above)
- Email me when you ship it
Message or Instructions To The Pharmacy
CAPTCHA
Email
This field is for validation purposes and should be left unchanged.

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