Pharmacy Care Centre Online Prescription Filling

Place your order here.

Name

Address

City

State

Zip

Phone

Home

Work

Refill Prescription

Prescription Number or Name of Medication

Medical Equipment

Equipment Needed

Pick Up

Delivery

Approx. Time of Pick Up

Billing

Insurance	Private Pay
Medicaid	Medicare

If not private pay, please submit the following information:

Payment
Cash
Pharmacy Care Centre Charge
Credit Card (Phone: 319-462-3306 Fax: 319-462-6065)