Cape Fear Prescription Request

Please use the form below to submit prescription refill and transfer requests for delivery to the Cape Fear Pharmacy only (There is an different form for pick-up at the Medical Mall). Please allow one business day for your request to be processed.

Request_type *	Prescription Refill - Cape Fear  Prescription Transfer - Cape Fear
First Name *
Last Name *
Employee Badge Number
Date of Birth *	mm/dd/yyyy
Phone *
Email Address
Prescription Number(s)(if known)
Name of Medication(s) Needed
Method of Payment	Payroll DeductMedical Expense Account
Medical Expense Account Number
Medical Expense Account Expiration Date
Special Instructions
Information Required for Transfers Only (If not transfering then proceed to next section)
Address
Address 2
City
State	AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming
Zip
Allergies
Transfering Pharmacy Name
Transfering Pharmacy Phone
Check Box If You Have United Healthcare Insurance
If checked, Patient's Name on Card
Subscriber Number
Relationship of Patient to Cardholder
Non Prescription Items Requested: Price List Here (If none proceed to the submit button at the bottom.)
Afrin Nasal Spray Oxymetazoline 0.05% HCl (1 oz)	012
Aleve Naproxen Sodium 220 mg tablets (50)	012
Alcohol Prep Pads (100)	012
Benadryl Diphenhydramine 25 mg capsules (24)	012
Benadryl Diphenhydramine 12.5 mg/5 mL syrup (4 oz)	012
Blistex Medicated Lip Ointment	012
Natural Ice Chapstick	012
Claritin Loratidine 10 mg tablets (30)	012
Claritin Loratidine 10 mg tablets (90)	012
Colace Docusate Sodium 100 mg tablets (100)	012
Daily Multivitamin Adult Tablet (100)	012
Daily Multivitamin Children's Chewable Tablet (60)	012
Dimetapp Elixir Brompheniramine 1mg/Pseudoephedrine 15mg/15mL (4oz)	012
Ecotrin Enteric-coated Aspirin 81 mg tablets (120)	012
Ferrous Sulfate 325 mg tablets (100)	012
Fleet's Saline Laxative Enema (4.5 fl oz)	012
Fleet's Saline Laxative Phosphosoda (1.5 fl oz)	012
Hydrocortisone 0.5% Cream (30 grams)	012
Hydrocortisone 1.0% Cream (30 grams)	012
Immodium Loperamide 2 mg Caplets (18)	012
Immodium Loperamide 1 mg/5mL Solution (4 oz)	012
Insulin Novolin R, Novolin N, Novolin 70/30 (1 vial)	012
Maalox Regular Strength (5oz) Aluminum hydroxide/Magnesium hydroxide 200	012
Monistat-7 2% (45 grams) Miconazole nitrate 100 mg cream	012
Monistat-7 2% (7) Miconazole nitrate 100 mg suppositories	012
Motrin Ibuprofen 200 mg tablets (100)	012
Motrin Ibupofen 100 mg/5 mL suspension (4 oz)	012
Motrin Ibuprofen Infant Drops 40mg/mL (0.5 oz)	012
Mucinex Guaifenesin 600 mg (20)	012
Mucinex DM Guaifenesin 600 mg & Dextromethorphan (20)	012
Neosporin Triple Antibiotic Ointment (30 grams)	012
N'ICE cherry flavored - menthol 5 mg (20)	012
N'ICE citrus flavored - menthol 5 mg (20)	012
Pepcid Famotidine 10 mg tablets (50)	012
Prilosec OTC Omeprazole 20 mg tablets (14)	012
Prilosec OTC Omeprazole 20 mg tablets (28)	012
Robitussin Syrup Guaifenesin 100 mg/ 5mL (4 oz)	012
Robitussin DM Syrup Guaifenesin 100 mg & Dextromethorphan 10 (4 oz)	012
Robitussin Guaifenesin 100 mg & Codeine 10 mg/5 mL (4 oz)	012
Saline Nasal Spray (1.5 fl oz)	012
Sudafed PE Phenylephrine 10 mg tablets (18)	012
Tucks Medicated Pads Witch hazel medicated pads (40)	012
Tums Extra Strength Calcium Carbonate 750 mg (96)	012
Tums Extra Strength "Smoothie" flavored calcium carbonate 750 mg (60)	012
Tylenol Acetaminophen 500 mg caplets (100)	012
Tylenol Acetaminophen Children's Chewable 80 mg (30)	012
Tylenol Acetaminophen 80 mg/0.8 mL Infant Drops (0.5 oz)	012
Tylenol Acetaminophen 160mg/5mL Children's Suspension (4 oz)	012
Zyrtec Cetirizine 10mg tablets (100 tabs)	012
Zyrtec Cetirizine 1mg/mL syrup (4 oz)	012
Visine Tetrahydrozoline HCl 0.5 mg eye drops (0.5 oz)	012
Nicotine Replacement Patches - 7 mg/24 hr (14)	012
Nicotine Replacement Patches - 14 mg/24 hr (14)	012
Nicotine Replacement Patches - 21 mg/24 hr (14)	012
Nicotine Gum - 2mg (50)	012
Nicotine Gum - 4mg (50)	012
* Required