Thank you for transferring your prescription to Ridgeway Pharmacy! You are only a few short minutes away from completing the process. Please complete your enrollment by providing the following information in order to ship your order:

Home Delivery rate: $99 per 120 tablets.

Have questions or need help with the process?

Please call 1-800-630-3214 and we would be happy to assist you.

Shipping Address*

Birthdate*

Phone Number*

- -

If yes, please list all drugs allergies:

Please list any medications you take:

How do you want us to obtain your prescription?

Home Delivery rate is $99 per 120 tablets. Would you like to provide your insurance information to possibly save even more?

Please make sure the following information is associated with the credit card you are using. **NOTE, all charges for this account will be made to this credit card. If you would like to designate a different credit card for another individual on this account, please call us to make those arrangements.

Credit Card Number*

Security Code*

Expiration Date: (Month - Year)*

Opt-In for Automatic Refill (We will automatically refill your prescriptions at the appropriate time, unless you cancel.)

Request Overnight Shipping for $22 (NOT AVAILABLE TO ALASKA OR HAWAII)

Opt-In for Communication - By checking this box you are confirming that you have read and understand the Ridgeway Pharmacy Privacy Policy, and provide your consent to Ridgeway Pharmacy to use information you provide as outlined in that policy.

Home Delivery rate: $99 per 120 tablets.

Have questions or need help with the process?

Please call 1-800-630-3214 and we would be happy to assist you.

Our Location:

Contact Us:

Patient

Home Delivery rate: $99 per 120 tablets.

Have questions or need help with the process?

Please call 1-800-630-3214 and we would be happy to assist you.

Contact Information

Allergy Information

Transfer Information

Payment Information

Our Location:

Contact Us:

Patient