Refill Order Form
SWR100
First name
Last name
Phone number:
(
)
Date of birth:
Affiliate
Swift RX (SWR100)
Agent Code (if applicable)
Drug name and strength
Quantity requested
Rx number
Please mail this form to:
Global Health Management: Suite 770, 2710 - 17 Ave S.E. Calgary AB T2A-0P6
ph: 1-866-266-9955 fax: 1-866-252-7137