Request Prescription

* First Name:	* Last Name
E-mail
* Contact Phone #	Alternative Phone #

Please transfer my prescription to Cloverdale Pharmasave: Yes

Name of current Pharmacy

Phone # of Pharmacy

* Prescription Number
(top left of label)

* Same quantity as last time?
If different quantity, please specify change**

Prescription Number

(top left of label)

Same quantity as last time?
If different quantity, please specify change

Prescription Number

(top left of label)

Same quantity as last time?
If different quantity, please specify change

** Your Doctor, your insurance plan, or Pharmacare may only allow no more than 30 or 90 days supply.

* Requested pick up day:

Requested pick up time:

Special Instructions

I would like to be called when my prescription is ready.

I would like my prescription mailed to me: Yes

Address:
City:
Postal Code:

Shipping charges for regular mail service in the B.C. lower mainland region is between $5-$10. We will contact you prior to shipment should the charges exceed $10.

*** Preparation of compounded prescriptions require specialized equipment and additional time and resources.

Please allow 2-3 working days for your custom made medication.

Submit

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Pharmacy:

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