Please complete this secure form to transfer your prescriptions to BILH Pharmacy Direct, a prescription delivery service. You may also use this form for your friends and family. A team member will contact you to finalize your request.

Please enter your first and last name.

Please enter your date of birth (MM/DD/YY).

Please enter the best phone number to reach you (XXX-XXX-XXXX).

Please enter your email address.

Please enter the name, address, and phone number of your current pharmacy.

Which medications you would like refilled including any supplies that are needed (needles, alcohol swabs, sharps container).

To have your medications sent to your home, please enter the delivery address and the date you need to receive the medications.

Do you grant us permission to transfer your prescription(s) to BILH Pharmacy Direct?

Thank you for trusting BILH Pharmacy Direct to service your pharmacy needs. A pharmacy team member will contact you within 48 business hours. If you require immediate assistance, please call our enrollment hotline at (781) 352-6500.