Medication Refill

    Your Details

    Last Name*

    First Name*

    Phone Number*

    Email*

    Patient's Name*

    Immunotherapy

    Medications

    Welcome to upload a photo of the prescription label instead of manually inputting medications.

    Name of Medication Strength/Size
    (Ie: 200mg or 236mL bottle)    		 Frequency
    (How often are you administering?)    		 Amount
    (Ie: 30 tablets or 1 bottle)    		 Picture
    (Upload a picture of the label)

    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

    Address

    City

    Province

    Postal Code

    A team member will contact you once your order is ready to ship with the cost and tracking information.

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