Thank You For Submitting Your Order
[ OCM ]
Your information has been sent
directly to the Pharmacy in Canada. The final step is to print
this page, fill out the information below, and fax it to us as a
cover page to complete your order. Please ensure that you
do not cover up any parts of your prescription! Print more pages
if you need to. |
Fax Number: 1-866-252-7137
Total Number of Pages
(including this sheet)  |
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| Your Name: (as
written on prescription) |
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| Address: |
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| Home Phone: |
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| Birth Date: |
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| Number of Prescriptions In This
Order: |
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Please attach Prescription to the Box Below
Before Faxing:
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