Prescription Refill Form

Complete 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*
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 Prescriptions
You may include up to six prescriptions.
Instructions
- You may include up to six prescriptions.
- You must include a Medication Description OR Prescription Number.
- If you use a prescription number, please make sure it's the most recent prescription number.
How Many Prescriptions Would You Like Us To Refill?
Prescription 1
1. Medication Description OR Prescription number
Prescription 2
2. Medication Description OR Prescription number
Prescription 3
3. Medication Description OR Prescription number
Prescription 4
4. Medication Description OR Prescription number
Prescription 5
5. Medication Description OR Prescription number
Prescription 6
6. Medication Description OR Prescription number
Pick Up & Delivery
Select One*
- I will pick up my prescription
- I would like my prescription delivered. (I understand there may be a reasonable delivery charge).
Prescription Pick-Up Date*
Please let us know when you would like to pick up this prescription at our location. (This is required).
MM slash DD slash YYYY
Address
Street Address City Postal Code
Special Instructions
Use this field to include any extra details you feel we may need to know when filling your prescription.

Prescription Refill Form

Your Prescriptions

Instructions

Pick Up & Delivery

Surlang Medicine Centre Pharmacy

Contact Information

Surlang Pharmacy Business Hours