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Request for Medication Refill and Over the Counter Products

Please complete the following form and click Submit. We will contact you as soon as possible regarding your request.

 

**Please note some medications require exams and regular blood work**

Last Name *
 Patient Name *
Street Address
City
 Province
E-mail Address *
Contact Phone*
 How do you wish to be contacted?
Medication Requested and Over the Counter Products*

* Required to submit this form










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