Prescription Refill FormComplete the form below. It will be sent to our pharmacy staff who will use the information provided to confirm, and refill your prescription for you.Name* First Date of Birth* Date Format: MM slash DD slash YYYY Phone*Email* Note: If you do not receive an automated e-mail message within 24-hours to confirm your on-line prescription refill(s) request, please phone 604-533-1041 for personal assistance.Your PrescriptionsAt least one prescription number is required. You may include up to six prescription numbers.How Many Prescriptions Would You Like Us To Refill?1234561: Prescription Number2: Prescription Number3: Prescription Number4: Prescription Number5: Prescription Number6: Prescription NumberPick Up & DeliverySelect One*I will pick up my prescriptionI would like my prescription delivered.Prescription Pick-Up Date*Please let us know when you would like to pick up this prescription at our location. (This is required). Date Format: MM slash DD slash YYYY Address Street Address City Postal Code Special InstructionsUse this field to include any extra details you feel we may need to know when filling your prescription.