TO: Biosense Pharmacy
c/o www.CanadaDrugSuperstore.com
235-13500 Maycrest Way Richmond BC V6V 2N8 Canada
Invoice:
Ordered:

 

I hereby FAX / MAIL a copy of my prescription along with a copy of my picture ID.
I understand that the positive identification is required to have my prescriptions filled in British Columbia, Canada.  [Click to print this form]

 

1.

ATTACH
PRESCRIPTION
HERE

2.

ATTACH
A COPY OF YOUR PICTURE ID
HERE


ACCEPTABLE PICTURE ID:
_______________________

  • Driver's license
  • Passport
  • Military card
  • Birth certificate (for minors*)

*If you are ordering for your children under 18 years old, please attach his/her birth certificate.

 

 
 

*ATTENTION FOR REFILLS*

If you are ordering your prescription refill, you do NOT need to submit this Fax form again as we already have received your prescription and your picture ID when you placed your first order.

Patient Name:

 

Signature: ___________________ , TEL:__________________   Date: _________________
( Month / Day / Year)

PRINT AND FAX TO: TOLL FREE FAX (+1) 877-832-7960 or LOCAL FAX (+1) 604-278-7960
(Please note our number is NOT [1-800], please make sure to send it to [1-877])