For Internal Use Only

 

 
Data Entry
Allergy PHN
Fill RX
RX History
Verified
         
Check DIN
Check Pharm
Pack
Counsel
  
         
 

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 for the refill of my prescriptions.
       
Signature of Credit Card Holder
Date:

 

Prescriptions to refill
*note we can only ship a 90 day supply according to FDA law
Medication
(example -. Liptior 20mg)
Quantity Requested
(example - 100 tablets)