NAME*
EMAIL*
PHONE*
ADDRESS
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Rx #
		(located in upper left corner of label)
DELIVERY METHOD		Pick-Up Deliver to address above Mail to this address
COMMENTS

RX REFILL

Please note: You have chosen to have your prescription refilled at

Herbst Pharmacy
2330 S. Dixon Road,
Kokomo, IN 46902

Please allow our pharmacy a minimum of one hour before pick-up at this location.