USCanadianPharmacy.com
EXISTING CUSTOMERS - New or Replacement Prescriptions
Please fax this form to 1-866-266-9944

NOTES:
  1. THIS FORM IS FOR EXISTING CUSTOMERS ONLY. IF YOU ARE A NEW CUSTOMER PLEASE USE FORM A.
  2. THIS FORM IS ALSO USED FOR REPLACEMENT PRESCRIPTIONS. A REPLACEMENT PRESCRIPTION IS A NEWLY ISSUED PRESCRIPTION FOR A DRUG PREVIOUSLY ORDERED (NO CHANGE IN STRENGTH OR DOSAGE).
* Denotes a Required field. These fields are required to be filled in prior to us processing your order.
(Please print clearly)
*First Name:   *Last Name:  
*Phone:   Email:  
 

Please enter the new prescriptions that you wish to order.

I will fax in my original prescription for the above order
My physician will fax in my original prescription for the above order
I will mail in my original prescription for the above order
 

You may also order refills on your existing prescriptions at this time. Enter your refill prescriptions and Rx numbers that you wish to be refilled here.

 

Have there been any changes in your billing information since your last order? If so please fill in below.
CREDIT CARD CHECKING ACCOUNT
* Name on Credit Card:   * Account Holder's Name:  
* Credit Card Type: Visa Mastercard * Account Number:  
* Credit Card Number:   * Bank Routing Number:  
* Expiration Date: Month_______ Year____________ * Drivers License Number OR Mother's maiden name:  
* Cardholder's Signature:  
 

 


Have there been any changes in your Health Profile since your last order? If so please fill in below.

 

Have there been any changes in your Delivery Address since your last order? If so please fill in below.





Attach a copy of your original prescription here!
 
* * * IMPORTANT * * *
Law requires that the full patient name, address (and telephone number) must be CLEARLY PRINTED on the written prescription in order for this prescription to be filled.

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