Please complete this form to submit your refill request if you have an active Xubex account and you have completed payment section of your profile. Please contact customer service at (866) 699-8239 with any questions or comments.

Patient Information First Name:  Last Name:    Phone:  Email Address:  Prescription Information Prescription 1:  Prescription 2:   Prescription 3: Prescription 4: Prescription 5: Prescription 6:   Prescription 7: Prescription 8: Comments(Text Only. Do not include html tags):

Activate Account To activate your online account provide a prescription number along with patient first and last name as stated on the prescription label. Prescription Number: Patient First Name: Patient Last Name: Patient Email: