Prescription Order Fax Cover Page



Print this page, fill out the information below, and fax it to us as a cover page to complete your order. 


Fax to: 1-866-327-8364 or 1-416-217-0199

Or mail to: 33 Coldwater Crt.,Thornhill, Ontario, L4J 7S4, Canada.

Web Order Reference Id:

Number of Pages (including this sheet):


Your Name: (as written on prescription)





Phone Number:

Number of prescriptions in this order:

Date of Birth (YYYY/MM/DD):

Please Attach Prescription to the Box Below Before Faxing:


Attach here!

Fax on separate page if prescription exceeds this box)

* * * IMPORTANT * * *
Law requires that the full patient name, address (and telephone number) must be CLEARLY PRINTED on the written prescription in order for this prescription to be filled