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Please fill out this form
Information with *is required.

*Name

*Phone Number
*Email Address
 
*Prescription #
 
*When do you plan to pick up your prescription?
 
Special Instructions
You may list any known drug allergies here.
 
If there are any supplements or you would like to pick up with your prescription, please list them here and we will have them ready.
 
Prescription Transfers
Rx# or Name of Medication to be transferred
Name of Pharmacy prescription is to be transferred from
Pharmacy Phone Number
 
 
Address: 25 Cabot Street, Beverly, MA 01915
Phone: 978.524.4800
Fax: 978.524.4809
Store hours: Mon – Fri. 9 am - 6 pm and Sat. by appt.
Email: info@custommedicine.com
Order your Refills online.
Prescription Refill Request or Transfer

You may request a prescription refill or transfer by filling out the form. Please be sure to include your e-mail address and a phone number where you can be reached in case we have a question regarding your prescription.