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Refill Request

Just fill out this simple form. Our pharmacy team will contact you to confirm your request and the details of your order. 

How to Request your Refill:

  1. Fill out the form and click "Submit"

  2. Check for confirmation message

  3. Wait for Aloma to contact you. *If you don't hear from us in 24 hours, please call the pharmacy, as your message may have been lost.
By sending your information to us, you are consenting to communicating with Aloma Pharmacy via electronic means. Please remember that these communications are not secure – however unlikely, it is possible that any information you submit can be intercepted and read by other parties. If you have any questions or concerns, please call us at 407-420-7996 or visit us in person.
Name *
Name
Patient's Name
Phone Number *
Phone Number
Is this a Rx Refill or Transfer? *
To fill a new Rx, please call or visit us.
Date of Birth
Date of Birth
*Required for Rx transfer only
*Required for Rx Transfer only
*Required for Rx Transfer only
*Required for Rx Transfer only
Current Pharmacy Phone Number
Current Pharmacy Phone Number
*Required for Rx Transfer only
Is there anything else you would like us to know?