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* 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). 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.