Refill Order Form PHO-100
 
First name  
Last name  
Phone number:
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Date of birth:  
Affiliate Pharmacy-Online (PHO-100)
Affiliate agent code
 
Drug name and strength Quantity requested Rx number
 
 		  
 		  
 
 
 		  
 		  
 
 
 		  
 		  
 
 
 		  
 		  
 
 
 		  
 		  
 
 
 		  
 		  
 
 
 		  
 		  
 
Please mail this form to:
Extended Care Pharmacy Ltd. # 202, 6420 - 6A Street S.E. Calgary, AB CANADA T2H-2B7
ph: 1-866-266-9955 fax: 1-866-252-7137