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)
Address:	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