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2. Make sure we get a copy of your new prescription and photo identification. 3. Fax to 604-685-9721 T 604-687-2564 Prescription Refill Form Patient’s Name (print) __________________ Phone # _________________ Mailing Address ______________________ Patient’s Signature ____________________ It is mandatory that you have had a complete physical examination in the past 12 months. Have you had one? ____ YES ____ NO
Medication Being Ordered DRUG__________________ RX #__________________ NAME__________________ STRENGTH__________________ QUANTITY__________________
______________________ Visa _______________________ MasterCard Name on Card________________________ Address ___________________ Credit Card # _________________________ Expiry Date ________________ Signature ____________________________ Date ______________________ Any changes in your health profile? ____ YES ____ NO Any changes in your mailing address? ____ YES ____ NO fax or phone order or Email:
krippsrx@gmail.com
PRIVACY STATEMENT |