Thank you for visiting Kelsey-Seybold Clinic’s Pharmacy Online. For your convenience, you can now pay for your prescription refills by credit card. We also offer free mail-to-home prescription delivery service.

Please provide the appropriate prescription refill information as indicated by the form below. Please allow 48 hours if physician authorization is needed.

1. You will receive a confirmation email, please review.
2. Your order will be entered into the Kelsey-Seybold pharmacy system.
3. A pharmacy representative will contact you to confirm total to be charged.
4. Your order will be shipped or you will be contacted that your order is ready for pick up.

1. PERSONAL INFORMATION We need these details for billing, mailing and contact purposes; otherwise they are kept confidential. = Required Field(s) First Name Last Name Date of Birth   mm/dd/yyyy Mailing Address City State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington, D.C West Virginia Wisconsin Wyoming Zip Phone Number Email Address

2. PAYMENT INFORMATION Payment Type I'd like to pay at pick up (see #4 below). I'd like to pay by credit card (please complete information below). Credit Card Select a Credit Card Type ------------------------------------- VISA Discover American Express MasterCard Credit Card Number Expiration Date   mm/yyyy Billing address same as above, otherwise enter below. Billing Name Billing Address City State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington, D.C West Virginia Wisconsin Wyoming Zip I authorize Kelsey-Seybold Clinic Pharmacies to bill my credit card. I understand that my credit card will be billed the following amounts in effect at the time my order is filled, along with any applicable co-payment(s), coinsurance and/or deductible(s), payments due for medications not covered under my benefit plan and shipping charges for controlled substances.

3. PRESCRIPTION Please enter the numbers of ALL prescriptions and names of all medications you would like to refill. Do not enter other information here. Prescription Number(s) Name(s) of Medication Select the clinic pharmacy that originally filled your prescription. Pharmacy where prescription was filled Clear Lake Medical Center Cypress Fort Bend Humble Katy Kingwood Lakes at 610 (*For KS employees only) Main Pasadena Spring The Vintage The Woodlands West

4. PICK UP/SHIPPING New! Now offering free mail-to-home prescription delivery service! Pick Up Location Select a location for pickup ------------------------------------- Clear Lake Medical Center Cypress Fort Bend Humble Katy Kingwood Lakes at 610 (*For KS employees only) Main Pasadena Spring The Vintage The Woodlands West Yes, I would like to be called when my prescription is ready. Yes, I would like to take advantage of the FREE mail-to-home prescription delivery service.