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Prescription Refill Full Name*: Phone*: Email*: Delivery Type*: Pickup   Delivery (Before 2:00 pm)  Delivery (After 2:00 pm) Pickup/Deliver*: Today   Tomorrow   Sometime Later Pickup Time: 8:30 AM 9:00 AM 9:30 AM 10:00 AM 10:30 AM 11:00 AM 11:30 AM 12:00 PM 12:30 PM 1:00 PM 1:30 PM 2:00 PM 2:30 PM 3:00 PM 3:30 PM 4:00 PM 4:30 PM 5:00 PM 5:30 PM 6:00 PM  * (If Pickup is for Today or Tomorrow) *For same day delivery there must be valid refills and it must be submitted before 2PM Delivery Comments: Delivery Address*: Keep on file Address: City: State: Zip: Enter Your Prescription Numbers: If you have additional prescriptions you w ould like to add or you dont know the prescription number please enter them here:

Contact us   Address 4004 Panama Lane,suite 100, Bakersfield, Ca 93313 Email panamapharmacy@gmail.com Phone 661.664.8864 Fax 661.831.1343 Business information Panama Compounding Pharmacy & Medical Supply Hours of Business Monday - Friday : 9:am -6:pm Saturday : 10:am-1:pm Sunday Closed

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