Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Phone *

(###)

###

####

Request Type *

For privacy reasons, the message box has intentionally been removed from this form. A TLC Xpress Pharmacy staff member will contact you by phone to complete your request.

General Inquiry

Refill Request (current TLC Xpress patient)

Transfer my prescription (new or returning patients)

Sign up for FREE delivery (patient must live or work within 3 miles of TLC)

Are you a *

New patient

Existing patient

Returning patient