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StatePharm Rx

Refill request

Submit your compounded prescription refill details for our team to review.

Submit your request for a prescription refill

Refill request form

Once received, a member of our staff will verify your information and confirm prescription eligibility before processing.

Patient name

First name *
Last name *

Contact & identification

Date of birth *
Phone (US) *
Email *

Prescriptions (Rx # & medication)

Choose how many prescriptions you are refilling (up to 6). For each row, enter an Rx #, a medication name, or both, only one is required, but both fields cannot be left empty.

How many prescriptions are you requesting? *

Prescription 1

Rx # (optional if medication given)
Medication name (optional if Rx # given)

Prescriber (optional)

If you know your prescriber's details, you may add them here. You can still submit the refill without this section.

Prescriber name (optional)
Prescriber phone (optional, US)

Fulfillment method

Notes

Notes (optional)

Communications & privacy

Choose SMS and/or email, then confirm data processing.

Frequently asked questions

Quick answers about refills and how we work with you.

  • Your prescription (Rx) number is printed on your StatePharm Rx label, usually near your name and the medication name. If you cannot locate it, call us at 888-373-2445 and we can help.

  • Yes. When needed, our team can reach out to your prescriber’s office. Response times vary by practice.

  • Yes. Use the form on this page to tell us what you need. We will confirm eligibility and next steps.

  • You can choose patient pickup at our pharmacy or request shipping. If you select shipping, please include a complete delivery address in the form.