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EXISTING CUSTOMERS
WITH A REFILL


1. Print out Order Form for Existing Customers

2. Make sure we get a copy of your new prescription and photo identification.

3. Fax to 604-685-9721
or Mail to: CANADA GLOBAL DRUGS
5413 West Boulevard
Vancouver, B.C.
Canada V6M 3W5.

T 604-687-2564
Toll Free: 1-877-312-8822
F 604-685-9721

Prescription Refill Form

Patient’s Name (print) __________________

Phone # _________________

Mailing Address ______________________
______________________ Email ___________________
______________________

Patient’s Signature ____________________
Family Physician Name _________________ Phone # __________________

It is mandatory that you have had a complete physical examination in the past 12 months. Have you had one? ____ YES ____ NO

 

 

Medication Being Ordered

DRUG__________________

RX #__________________

NAME__________________

STRENGTH__________________

QUANTITY__________________


Payment:
Any changes to your credit card information? ____ YES ____ NO
If yes, new information:

______________________ Visa

_______________________ MasterCard

Name on Card________________________

Address ___________________

Credit Card # _________________________

Expiry Date ________________

Signature ____________________________

Date ______________________

Any changes in your health profile? ____ YES ____ NO
If yes, please specify.

Any changes in your mailing address? ____ YES ____ NO
If yes, please indicate.

fax or phone order or
mail to: Canada Global Drugs.com

T 604-687-2564
F 604-685-9721

Email: altermed@portal.ca
Address: CANADA GLOBAL DRUGS
5413 West Boulevard
Vancouver, B.C.
Canada V6M 3W5.


PRIVACY STATEMENT
All information you provide is confidential. Information on this site is solely for educational and reference purposes. It is not intended as a substitute for diagnosis or treatment with a qualified health professional.

LIABILITY DISCLAIMER