For Internal Use Only

 

 

Data Entry
Allergy PHN
Fill RX
RX History
Verified
         
Check DIN
Check Pharm
Pack
Counsel
 
         
Add new prescription form

STEP 1: Print and sign the forms below.

STEP 2: Fax completed forms along with a copy of your ORIGINAL PRESCRIPTION to Toll Free Fax 1-866-260-7981. If sending by mail, please send to:

Super Save Rx
#9 31205 Maclure Road
Abbotsford BC Canada V2T 5E5
Toll Free Phone 1-866-260-7980
email: info@supersaverx.com

STEP 3: Please allow approximately 10-14 business days from the time we receive your order to final delivery, to account for order processing, verification, and delivery time.

A) PATIENT INFORMATION

First Name:
 

Last Name:

         
Address:
         
City:
 
State:
         
Country:
 
Zip:
         
Telephone:
 
Alternate Telephone:
         
Fax:
 
Email:
         
Birth date:
(dd/mm/yy)
 
Gender:

B) PAYMENT INFORMATION (VISA or MasterCard #)

Visa MasterCard
   
Card Holder Name
   
Credit Card #
         
Expiry Date (mm/yy):
     
         
Credit Card Verification Number
     
         
Example
 

 

Signature of Consent

I authorize the pharmacy to charge my credit card to add new prescriptions to my order
       
Signature of Credit Card Holder
Date:

 

Prescription to add

*note we can only ship a 90 day supply according to FDA law
Medication
(example -. Liptior 20mg)
Directions
(example - Take one tablet
once per day)
Quantity Requested
(example - 100 tablets)
   
   
   
   
   
   
   
   
   
   

 

             
 
Yes
No
   
I would like the pharmacy to substitute generic drugs wherever possible to save me even more money.
   

 

   
attach prescription here