Online Prescription Refill Form

Please complete the form and then click the "Submit Order" button to send your order. Note: For USPS delivery requests, please allow 7 business days for processing and delivery.

To refill a prescription at an SSM Health Pharmacy or Prescription Center in the Greater Fond du Lac region, please login to MyChart.

Your Prescription Number(s) and/or Drug Name(s):

List date and time you will pick up your medication. We request a 24-hour notice for refills so we can work through any unexpected issues.

Check method of payment for this service

We will bill your credit card on file. Please confirm the information requested to prevent delivery delays. If we don't have your credit card on file we will call you.