Quality Prescription Drugs mail/fax orderform

Fax to: 1-877-868-4804
Or mail to:
Canada Online Healthlink Inc. on behalf of QualityPrescriptionDrugs.com
Suite #245
7360 137th Street
Surrey, B.C.
V3W 1A3

Cover sheet

Total Number of Pages (including this sheet):

Your Name (as written on prescription):

1. Complete and sign the attached form

2. Fax toll-free 1-877-868-4804 along with a copy of your original prescription and a copy of a Picture ID or 2 of the following: birth certificate, passport, voter's card, marriage certificate, or military ID.

** Please note: if you order your prescriptions by mail, there is a $9.00 USD shipping fee ($15.95 USD for cold-pack items) per patient for an unlimited number of prescriptions. All prescriptions will be authorized for a 1-year period if indicated by the physician and will be honoured from the date on the prescription form. All prescription drug prices include pharmacy dispensing fee.

Please Attach Prescription to the Box Below Before Faxing:

Cart details

Billing address

First Name:

Last Name:

Address:

City / Town:

State / Province:

Zip / Postal Code:

Email

Shipping address

First Name:

Last Name:

Address:

City / Town:

State / Province:

Zip / Postal Code:

Email:

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