Rx  Request fax back form for your doctor
For maintenance medication only

Patient Name: _______________________________
Address: ____________________________________
Telephone: ______________________
  Doctor Stamp Here
Doctor Name: _______________________________
Telephone: ______________________
Fax: ______________________

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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