MEDICATIONS CANADA :: PRESCRIPTION DRUGS FROM CANADA

Refill Order Request Form

To order a refill please complete the form below. You will be contacted if we have any additional questions. Completing this form is completely safe. All sensitive information is encrypted so that the only people who can read it are you and authorized Medications Canada staff.

Please note: we can only complete your order if you have refills left on your original prescription order. If you do not have any refills left, you must visit your doctor to obtain a new prescription and send it to us for processing.

* denotes required field

First Name:	*
Last Name:	*
Phone Number:	- *

		Rx#		Medication Name
Medications	1		or		*
	2		or
	3		or
	4		or
	5		or
	6		or
	7		or
	8		or
	9		or
	10		or

Billing Information (check one) *
1. Use the credit card you have on file (fastest method)
2. I will be mailing in a money order
3. Use the following new credit card information

Card Number:		Visa
		Amex
Expiry date:		Master Card

Has your shipping address changed since your last order? (if so, please complete the following information)

Address Line 1:
Address Line 2:
City:
State:
Zip Code:

Have there been any changes to your Health profile?

(if so, please complete the following information)

First Time Visitor?

Discover the huge cost saving advantage of purchasing your medications through a licensed CANADIAN pharmacy.

Our order process is easy
as 1 – 2 – 3!

Canadian Pharmacy Facts

Ø	Read what people are saying about Medications Canada.
Ø	Are medications from Canada safe?
Ø	Learn more about generic drugs.
Ø	Are Canadian pharmacies regulated?
Ø	Canadian pharmacists are health professionals.

All prescriptions are filled by an
accredited online Pharmacy.
Click on graphic to see details:


	CALL NOW 1-866-481-5817 (24 hour service centre)

Our order process is easy as 1 – 2 – 3!

Our order process is easy
as 1 – 2 – 3!