Fertility Medication Refills

Refilling your prescriptions has never been easier! Just enter your prescription information in the fields below.

Choose a location to have your medications refilled at:*
- Millard (12741 Q St)
- Lincoln (808 N 27th St)
Please have my medication ready by:*
MM slash DD slash YYYY
Would you like notified when your refill is ready?*
- YES
- NO
Delivery method:*
- Mail
- In-store pick-up
Personal Information
Name*
First Last
Date of Birth*
MM slash DD slash YYYY
Phone*
Email*
Medication
Medication Selections
- Crinone 8%
- Endometrin
- Follistim 300
- Follistim 600
- Follistim 900
- Ganirelix 250mcg
- Menopur 75 Units
- Pregnyl
- Progesterone in Oil
Medication Quantities
Please indicate the quantity desired for each of the medications selected above.
Crinone 8%*
Endometrin*
Follistim 300*
Follistim 600*
Follistim 900*
Ganirelix 250mcg*
Menopur 75 Units*
Pregnyl*
Progesterone in Oil*
Hidden
Comments
Additional Comments / Special Instructions

Personal Information