Last Name*
First Name*
Phone Number*
Email*
Patient's Name*
Immunotherapy Re-Order (orders will be ready for pick up on Wednesdays, immunotherapy order deadline is Mondays at 10 PM)
If injectable immunotherapy, do you require syringes?
Name of Medication*
Strength or size of medication* (Ie: 200mg or 236mL bottle)
Frequency you are giving the medication currently*
Amount of medication to be refilled* (Ie: 30 tablets or 1 bottle)
Are you ordering multiple medication refills?
Name of Medication
Strength or size of medication (Ie: 200mg or 236mL bottle)
Frequency you are giving the medication currently
Amount of medication to be refilled? (Ie: 30 tablets or 1 bottle)
If you also would like to order food please specify what type and what size you’d like.
Type of Food
Size of Bag
Please specify what day you’d like to pick up your order. If you require a refill within less than 24 hours please call the clinic at 403-370-8800
If you require more than 4 prescription refills, please submit another form.
Address
City
Province
Postal Code
A team member will contact you once your order is ready to ship with the cost and tracking information.