Johnson Drug & Home Medical - Prescription Order Form

Use this form to order prescriptions to the Williamsburg Pharmacy only

2200 Gum Branch Rd.
Jacksonville, NC 28540
Phone: 910.938.0582
Fax: 910.938.0239

To order prescription(s) online, simply complete the Refill Request form below (e-mail address is optional).

* INDICATES REQUIRED FIELD

Patient Information

First Name*:   Last Name*:  

Date of Birth*:

Street Address*:   City*:  

State*: Zip*:

Phone number where someone can reach you during the day*:

E-mail (only required if you would like the pharmacy to confirm your refill request):

Insurance Information

Insured Name*:    Primary Insurance Carrier*:

Policy / Group #*:    Member #:

Secondary Insurance Carrier:

Policy / Group #:    Member #:

Prescriptions

Please enter the prescription number(s) you wish to refill at this time. This number is located on your prescription label. ALL PRESCRIPTIONS ENTERED MUST MATCH THE LAST NAME AS ENTERED ABOVE.

Prescription #1:   Prescription #5:
Prescription #2:   Prescription #6:
Prescription #3:   Prescription #7:
Prescription #4:   Prescription #8:

Would you like the pharmacy to contact your doctor if your prescription needs authorization?  Yes No

Doctor name:   Doctor Phone #: