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SEND US YOUR NEW PRESCRIPTIONS   

Only print this form if you are ordering a prescription medication. Print and fax this form along with your original prescription to us.

If you are only ordering over-the-counter products you do not need to fax us this form.
 
Please allow 24 hours for one of our customer service specialists to contact you and confirm your order information. If you do not receive a confirmation call within this time please contact us.

                 PLEASE FAX THIS FORM TO 1-866-879-2441

Confirmation:                                           Name on Prescription: 
Address:                                                   Phone Number:

PLEASE ATTACH YOUR PRESCRIPTION BELOW
www.USDrugStoreOnline.com
202B - 8322 130 Street, Surrey, BC Canada, V3W 8J9
Toll-Free Phone: 1-866-815-3784 Toll-Free Fax: 1-866-879-2441
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