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Prescription Refill Appointment and Information Form

Please fill out your details and appointment information to receive your prescription refill promptly. For refund, we deduct $20 charges because of administration charges and payment gateway charges.
Full Name*

First NameLast Name
Phone*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Address*

Street Address

CityState / ProvincePostal / Zip Code
Date of Birth*

MonthDayYear
Date
Prescription Refill Information
Reason for Prescription Refill*
Up to 3 medications $60
Proof of current use of the requested drug is needed (bottle snap shot or so)
We do not refill controlled drugs
Upload Files or Photos

Accepted: PDF, DOC, DOCX, JPG, JPEG, PNG, GIF
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Doctor Prescription Refill*

Prescription Refill

Request and receive your official Prescription Refill after your appointment.

$60.00CAD

Total

$0.00CAD