_______________________________
Doctor Name
______________________
Telephone
______________________
Fax
Rx  Request fax back form for your doctor
QAA
       
 
       
For maintenance medication only
 
Patient Name: _______________________________
Address: ____________________________________
Telephone: ______________________
  Doctor Stamp Here
   


Rx Name SIG Qty Reps
       
       
       
       
       
       

* Please indicate if any of the medication is new to the patient        Yes        No 

Doctor Name : ______________________________________________


Doctor Signature  : ______________________________________________


Licence #  :____________		Date  : ________________________

Please use this form for maintenance medications (3 months supply) or attach
prescription and fax back to pharmacy at 1-877-948-0464.
Please issue separate RX for narcotics, antibiotics and controlled substances
(benzodiazepines) to patient.
Thank You !

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