Medication Refill Form

Patient MRN *

Patient Name *

National ID *

Pickup method * - Select - Through SMSA express mail (Registered only, conditions apply)

Location/Address *

Mobile Number *

Notes

Service Terms and Conditions

• The form should be filled out from 8 am to 3 pm; and will be received the following day.
• Forms submitted after 3 pm will be received after 2 working days.
• Receiving times from Sunday to Thursday from 2 to 4 pm.  
• Medication ready for pickup will be kept at the pharmacy for 1 working day.
• Shipping services fee: 32 SAR for room temperature medication and 50 SAR for refrigerated medication.