Prescription Refills Online

To refill prescription(s) online, simply complete the Refill Request form below (e-mail address is optional).

* INDICATES REQUIRED FIELD

Patient Information:

First Name: Last Name:
LAST NAME MUST BE ENTERED EXACTLY AS IT APPEARS ON THE PRESCRIPTION LABEL.
 
Phone Number: - - Email Address:
NUMBER WHERE YOU CAN BE REACHED IF THE PHARMACIST HAS A QUESTION. REQUIRED ONLY IF YOU WISH TO RECEIVE AN EMAIL CONFIRMING YOUR ORDER WAS RECEIVED BY THE PHARMACY.
 

Prescription Information:

 Please enter the prescription number(s) you wish to refill at this time. This number is located on your prescription label (see example). ALL PRESCRIPTIONS ENTERED MUST MATCH THE LAST NAME AS ENTERED ABOVE.
* Prescription #1
  Prescription #2
  Prescription #3
  Prescription #4
  Prescription #5
  Prescription #6
  Prescription #7
  Prescription #8

 
 
* Would you like the pharmacy to contact your doctor if your prescription needs authorization?
Yes    No
 
* Where would you like to pick up your prescription?
Polk St.
Oak Park (Delivery to this location requires pre-payment. Please contact the main Polk St. location to make arrangements for payment and delivery: 312-423-4260)
87th St (Delivery to this location requires pre-payment. Please contact the main Polk St. location to make arrangements for payment and delivery: 312-423-4260)
Northwest (Delivery to this location requires pre-payment. Please contact the main Polk St. location to make arrangements for payment and delivery: 312-423-4260)
   
 
Union Health Service, Inc.
1634 West Polk Street
Chicago, IL 60612
Phone: (312) 423-4200
Fax: (312) 423-4392