Prescription Request 药方
Please note that this may be processed within 48 hours and the prescribing clinician may require you to come in for formal review. We prefer correspondences by email.
Patient Name 名字
*
First Name
Last Name
Date of Birth 出生日期
*
-
Month
-
Day
Year
Date
Contact Number 电话号码
Email address 电子邮件
Are you an enrolled patient?
*
Yes
No
Do you want all your regular medications? 长期服药
Yes
No
Some of my regular
Do you need additional medications? 额外的药物
Medication Name
1
2
3
Preferred Pharmacy 药店
Submit
Should be Empty: