{"id":1756,"date":"2025-04-16T07:32:02","date_gmt":"2025-04-16T07:32:02","guid":{"rendered":"https:\/\/pharmacysites.wappnet.us\/jdxpharmacy\/?page_id=1756"},"modified":"2026-10-08T08:58:28","modified_gmt":"2026-10-08T08:58:28","slug":"refill-a-prescription","status":"publish","type":"page","link":"https:\/\/pharmacysites.wappnet.us\/jdxpharmacy\/refill-a-prescription\/","title":{"rendered":"Refill a Prescription"},"content":{"rendered":"\n<div class=\"et_pb_section_0 et_pb_section et_section_regular et_block_section\"><div class=\"et_pb_row_0 et_pb_row et_pb_equal_columns et_block_row\"><div class=\"et_pb_column_0 et_pb_column et_pb_column_1_2 et_block_column et_pb_css_mix_blend_mode_passthrough\"><div class=\"et_pb_text_0 et_pb_text et_pb_bg_layout_light et_pb_module et_block_module preset--module--divi-text--cd48c4ae-ff4b-4126-ad3f-ff80d3e5223b\"><div class=\"et_pb_text_inner\"><h1>Refill a Prescription<\/h1>\n<\/div><\/div><div class=\"et_pb_text_1 et_pb_text et_pb_bg_layout_light et_pb_module et_block_module preset--module--divi-text--c8496805-3cdf-4c6e-829a-f469d6038e7c\"><div class=\"et_pb_text_inner\"><h5>Complete our secure form below to become a new patient. Need help? Call us for immediate assistance <a href=\"tel:732-721-1732\">732-721-1732.<\/a><br \/>\n<\/h5>\n<\/div><\/div><div class=\"et_pb_module et_pb_button_module_wrapper et_pb_button_0_wrapper preset--module--divi-button--1bffc0fc-42a0-49d1-bd9a-ae3ade2d7206_wrapper\"><a class=\"et_pb_button_0 et_pb_button et_pb_bg_layout_light et_pb_module et_block_module preset--module--divi-button--1bffc0fc-42a0-49d1-bd9a-ae3ade2d7206\" href=\"#transfer-here\">Fill Out Prescription Form<\/a><\/div><\/div><div class=\"et_pb_column_1 et_pb_column et_pb_column_1_2 et-last-child et_block_column et_pb_css_mix_blend_mode_passthrough\"><div class=\"et_pb_image_0 et_pb_image et_pb_module et_block_module\"><span class=\"et_pb_image_wrap\"><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/pharmacysites.wappnet.us\/jdxpharmacy\/wp-content\/uploads\/sites\/63\/2024\/09\/transfer-prescription.webp\" width=\"900\" height=\"600\" srcset=\"https:\/\/pharmacysites.wappnet.us\/jdxpharmacy\/wp-content\/uploads\/sites\/63\/2024\/09\/transfer-prescription.webp 900w, https:\/\/pharmacysites.wappnet.us\/jdxpharmacy\/wp-content\/uploads\/sites\/63\/2024\/09\/transfer-prescription-480x320.webp 480w\" sizes=\"(min-width: 0px) and (max-width: 480px) 480px, (min-width: 481px) 900px, 100vw\" class=\"wp-image-1289\" alt=\"transfer-prescription\" title=\"transfer-prescription\" \/><\/span><\/div><\/div><\/div><\/div><div class=\"et_pb_section_1 et_pb_section et_section_regular et_block_section\" id=\"transfer-here\"><div class=\"et_pb_row_1 et_pb_row et_block_row\"><div class=\"et_pb_column_2 et_pb_column et_pb_column_4_4 et-last-child et_block_column et_pb_css_mix_blend_mode_passthrough\"><div class=\"et_pb_code_0 et_pb_code et_pb_module\"><div class=\"et_pb_code_inner\">    <div class=\"refill-form-container\">\n        <h2>Refill your prescriptions with ease. Simply provide your details below.<\/h2>\n        <p class=\"required-note\">Fields marked with * are required.<\/p>\n\n        <form id=\"refill-form\">\n            <div class=\"form-row\">\n                <div class=\"form-group\">\n                    <label for=\"first_name\">First Name*<\/label>\n                    <input type=\"text\" id=\"first_name\" name=\"first_name\" placeholder=\"Enter first name\" required>\n                <\/div>\n                <div class=\"form-group\">\n                    <label for=\"last_name\">Last Name*<\/label>\n                    <input type=\"text\" id=\"last_name\" name=\"last_name\" placeholder=\"Enter last name\" required>\n                <\/div>\n            <\/div>\n\n            <div class=\"form-row\">\n                <div class=\"form-group\">\n                    <label for=\"phone_number\">Phone Number*<\/label>\n                    <input type=\"tel\" id=\"phone_number\" name=\"phone_number\" placeholder=\"Enter phone number\" minlength=\"8\" maxlength=\"12\" pattern=\"\\d{8,12}\" title=\"Please enter 8 to 12 digits\" required>\n                <\/div>\n                <div class=\"form-group\">\n                    <label for=\"date_of_birth\">Date of Birth*<\/label>\n                    <input type=\"date\" id=\"date_of_birth\" name=\"date_of_birth\" placeholder=\"Enter date of birth\" max=\"2026-10-08\" value=\"\" required>\n                <\/div>                \n            <\/div>\n            <div class=\"form-row\">\n                <div class=\"form-group\">\n                    <label for=\"email\">Email Address*<\/label>\n                    <input type=\"email\" id=\"email\" name=\"email\" placeholder=\"Enter email address\" required>\n                <\/div>                                    \n            <\/div>            \n            <div class=\"form-group\">\n                <label for=\"rx_refill_numbers\">Prescription Numbers*<\/label>\n                <div class=\"prescription-input-group\">\n                    <input type=\"text\" id=\"rx_refill_numbers\" name=\"rx_refill_numbers[]\" placeholder=\"Enter RX Refill number\" required>\n                    <button type=\"button\" class=\"add-prescription btn-blue\">+<\/button>\n                <\/div>\n                <div class=\"form-group\">\n                    &nbsp;\n                <\/div>  \n            <\/div>\n            <div class=\"form-row\">\n                <div class=\"form-group\">\n                    <label>Add Over the Counter Prescription<\/label>\n                    <div class=\"otc-input-group\">\n                        <div class=\"form-row\">\n                            <div class=\"form-group\">\n                                <label for=\"otc_name\">Name<\/label>\n                                <input type=\"text\" id=\"otc_name\" name=\"otc_name[]\" placeholder=\"Enter Name\">\n                            <\/div>\n                            <div class=\"form-group\">\n                                <label for=\"otc_quantity\">Quantity<\/label>\n                                <input type=\"text\" id=\"otc_quantity\" name=\"otc_quantity[]\" placeholder=\"Enter Quantity\">\n                            <\/div>\n                            <div class=\"form-group add-btn-container\">\n                                <button type=\"button\" class=\"add-otc btn-blue\">+<\/button>\n                            <\/div>\n                        <\/div>\n                    <\/div>\n                    <div id=\"additional-otc\"><\/div>\n                <\/div>\n            <\/div>\n\n            <div class=\"form-row\">\n                <div class=\"form-group\">\n                    <label>Pickup or Delivery*<\/label>\n                    <div class=\"radio-group\">\n                        <label class=\"radio-container\">\n                            <input type=\"radio\" name=\"pickup_or_delivery\" value=\"pickup\" checked>\n                            <span class=\"radio-label\">Pickup<\/span>\n                        <\/label>\n                        <label class=\"radio-container\">\n                            <input type=\"radio\" name=\"pickup_or_delivery\" value=\"delivery\">\n                            <span class=\"radio-label\">Delivery<\/span>\n                        <\/label>\n                    <\/div>\n                <\/div>\n                <div class=\"form-group\">\n                    <label for=\"notify_when_ready\">Would you like us to notify you when your prescription(s) are ready?<\/label>\n                    <select id=\"notify_when_ready\" name=\"notify_when_ready\">\n                        <option value=\"no\">No, thanks<\/option>\n                        <option value=\"yes-sms\">Yes, Send me SMS<\/option>\n                        <option value=\"yes-call\">Yes, Call me<\/option>\n                    <\/select>\n                <\/div>                \n            <\/div>                    \n\n            <div class=\"form-row\">\n                                    <div class=\"form-group\">\n                        <label for=\"allergies\">Do you have any allergies?*<\/label>\n\n                                                    <input\n                                type=\"text\"\n                                id=\"allergies\"\n                                name=\"allergies\"\n                                placeholder=\"List your allergies\"\n                                required>\n                                            <\/div>\n                                \n            <\/div>\n            \n                            <div class=\"form-group\">\n                    <div class=\"cf-turnstile\" data-sitekey=\"0x4AAAAAADXRCWv3X8Yo3WY1\"><\/div>\n                <\/div>\n            \n            <div class=\"form-submit\">\n                <button type=\"submit\" class=\"submit-btn\">Submit<\/button>\n            <\/div>\n            <div id=\"refill-message\"><\/div>\n        <\/form>\n    <\/div>\n<\/div><\/div><\/div><\/div><\/div><div class=\"et_pb_section_2 et_pb_section et_section_regular et_block_section\"><div class=\"et_pb_row_2 et_pb_row et_block_row\"><div class=\"et_pb_column_3 et_pb_column et_pb_column_4_4 et-last-child et_block_column et_pb_css_mix_blend_mode_passthrough\"><div class=\"et_pb_text_2 et_pb_text et_pb_bg_layout_light et_pb_module et_block_module preset--module--divi-text--df96b77a-cd4f-44a8-a771-2d6347592b53\"><div class=\"et_pb_text_inner\"><h2>Contact Us Today<\/h2>\n<\/div><\/div><div class=\"et_pb_text_3 et_pb_text et_pb_bg_layout_light et_pb_module et_block_module et_pb_text_align_center preset--module--divi-text--41d5859c-fbaa-458a-88e4-5d886857f235\"><div class=\"et_pb_text_inner\"><p>We'd love to hear from you. Whether you have a question, concern, or feedback, feel free to reach out.<\/p>\n<\/div><\/div><div class=\"et_pb_module et_pb_button_module_wrapper et_pb_button_1_wrapper preset--module--divi-button--1bffc0fc-42a0-49d1-bd9a-ae3ade2d7206_wrapper\"><a class=\"et_pb_button_1 et_pb_button et_pb_bg_layout_light et_pb_module et_block_module preset--module--divi-button--1bffc0fc-42a0-49d1-bd9a-ae3ade2d7206\" href=\"\">Contact Us<\/a><\/div><\/div><\/div><\/div>\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":"","_members_access_role":[],"_members_access_error":""},"class_list":["post-1756","page","type-page","status-publish","hentry"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v28.5 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>Refill a Prescription - JDX Pharmacy Website<\/title>\n<meta name=\"robots\" content=\"noindex, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Refill a Prescription - 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