Infinum Health - Healthcare Transcended

Please allow 2 business days for refills. You will receive a text when refills are ready for pick-up. Thank you! *Indicates required field

First Name *

Last Name *

Date of Birth *

Email Address *

Phone Number *

Address 1

Address 2

City

State

Zipcode

Medication name #1*

Dose* (ex: 20mg)

Quantity requested* (ex: 90 pills)

Pick up?*

Medication name #2

Dose (ex: 20mg)

Quantity requested (ex: 90 pills)

Pick up?

Medication name #3

Dose (ex: 20mg)

Quantity requested (ex: 90 pills)

Pick up?

Medication name #4

Dose (ex: 20mg)

Quantity requested (ex: 90 pills)

Pick up?

Pharmacy

Note: If using using Infinum Health's pharmacy, I understand that my card on file will be charged for payment at time of dispensing.

Please list additional medications if needed. Be sure to include which pharmacy you prefer, if applicable. Thanks!

What is three plus 6? *

Refill Request