Wufoo

Kay Pharmacy Refill Request

Requesting refills online is easy--just fill in the information below!

Name on Prescription *
Phone (home or cell) * - (###) - ### ####
Email *
When would you like your prescriptions ready? Pick-up in 2 hours Pick-up in 4 hours Pick-up next day Deliver my refills for no extra charge (same day delivery if ordered by 2pm on weekdays or noon on Saturdays)
Refills ordered for delivery will be delivered the same day if ordered before 2pm on weekdays or noon on Saturday.

We deliver to all metro Grand Rapids, including Grand Rapids, Rockford, Ada, Byron Center Comstock Park & Allendale.
Street Address (only if delivery chosen above)
Prescription Refill Numbers

Please submit your prescriptions to be refilled in the boxes below (if you have more than 5 prescriptions to be refilled, simply enter the additional refill numbers in the comment box below):
Prescription Refill Number *
Next Prescription Refill Number
Next Prescription Refill Number
Next Prescription Refill Number
Next Prescription Refill Number
Questions, Comments, Medical or Insurance changes
Do Not Fill This Out