Transfer Form

First Name*

Last Name*

Cell Phone Number*

Email Address*

Preferred method of contact*

Picture of new prescription (if applicable)

If this is a new prescription, please attach the picture here. You can upload more than one prescription.

Image of your drug coverage card(s)

Please attach the picture of your drug coverage card(s) for billing.

Delivery Date*

Preferred Delivery Time*

Street Address*

Address Line 2*

City*

Province*

Postal Code*

Delivery Notes*

e.g. Leave at Joan at reception, place in mail box, call me when they are at the entrance.

At your next doctors' appointment: Please ask your doctor's office to fax your new prescription to 780-250-2617*

I understand and agree

Terms of Service*

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