Prescription Refill Online Form

* First Name:	* Last Name:
* Date of Birth -- month -- January February March April May June July August September October November December	* E-mail Address:
* Phone:	Cell:
Address:	Postal Code:
* Prescription Number(s) or Medication Name(s):
* Delivery Type Pick-up Delivery Courier Mail
Pick-up Time    We require a minimum of 30 minutes to prepare your refill.
Payment Type Cash Debit/Credit Other

* Sometimes recipient mail servers temporarily delay or block messages, or other technical issues could arise prohibiting your order from reaching our pharmacy. Please phone us at 204-638-4602 if you don't receive your order when you expected it.