Prescription Refill Request Fill out this form to submit your refill request directly to the Healthville Pharmacy.It will be delivered via secure fax, and we will notify you when it is ready to pickup. Refill Prescription (Quick) Personal Information First Name * Last Name * Phone * Date of Birth * Prescriptions to Refill Rx Number 1 * Rx Number 2 Rx Number 3 Rx Number 4 Comments * * Indicates required field CAPTCHA If you are human, leave this field blank. Submit Δ