Medication Refill Request

Full Name

Email

Phone

Medication Details:

Medication Name

Dosage

Quantity Requested

Preferred Pharmacy (if applicable)

By submitting this form, I consent to the refill of my medication.

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Full Name*

Phone*

Email*

Message*

Email*

By Appointment Only

Address: 200, 1620 29 ST NW, Calgary, AB, T2N 4L7

Phone: +1 403 371 5768

Fax: +1 403 538 6430

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