Your information has
been sent directly to our online Pharmacy. The final step is to print this
page, fill out the information below, and fax it to us as a cover
page to complete your order.
* NOTE * Due to the high volume of orders we receive. Please give us 72 hours before you try and call us to confirm receipt of your faxed prescriptions.
Fax to: 1-866-266-9944 Or mail to:
USCanadianPharmacy.com 745 Post Rd. Darien, CT USA 06820.
Web Order Reference Id:
Total Number of Pages (including this sheet)
Your Name: (as written on prescription)
Address:
Phone Number:
BirthDate: (YYYY/MM/DD)
Number of Prescriptions in this Order:
Please Attach Prescription to the Box Below Before Faxing:
Attach 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.