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This option is available to patients that have previously ordered form us. Please also be sure to inform us of any changes to your health profile, billing preferences or contact information.

First Name
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Informed Consent for Patient Counselling
All patients receiving prescriptions from our pharmacy have the right to receive counselling from a licensed pharmacist.
Would you like a pharmacist to call and discuss your order with you?
Yes     No
Are you sending a new prescription to be processed with this order? 
Yes     No  
Did your mailing address or telephone number changed since the last order?
Yes     No   (if yes, please specify above)

 

Refills Requested
*Fields required to be filled for your request.
 
*Medication Name As on prescription label Drug Strength
e.g. 10 mg/ml 		*Quantity
Number of tablets capsules, mls, etc. 		Generic
Allow generic
substitution


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