Requests sent will be responded to during regular business hours. Mon-Fri 9:00AM to 5:00PM. Any requests during the weekends or after hours are not guaranteed a response or action.

    First Name*

    Last Name*

    Your Email*

    Year of Birth* (4 characters)

    Phone Number*

    Prescription Numbers*

    Prescription #1

    Prescription #2

    Prescription #3

    Note: Your prescription # can be found on your prescription label.
    Also, if you have more than three (3) prescriptions, please fill out the form a second time.

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    2-8181 120A Street12-6828 128 Street125-8291 Ackroyd Road#104-8056 King George Blvd

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    Special Remarks

    Refill Prescription Here