New Prescription Form

Please fill out the form to the right to submit a new prescription online.  Take an image of your new prescription (using a camera, phone, or scanner, etc.), and upload it to the form on the right.  Please ensure that the image is legible.  You must present the original prescription to the pharmacy or delivery driver in order to receive your new medication.

Terms and Conditions

By filling out a new prescription submission form, you consent to allowing a pharmacist access to your personal health information. Furthermore, you agree to allow the pharmacist to disclose all prescription and personal health information to physician(s) and drug plans in order to maintain the standard of care when necessary.

ID may be requested upon pickup if a third party is picking up a refill on behalf of the patient.

In the case of a technical failure, Hespeler Pharmacy cannot be held liable for delayed or lost requests.

New prescriptions will NOT be released until the original prescription is presented to the pharmacy.

Terms and Conditions*

I have read and accept the Terms and Conditions.