Canada East Pharmacy: Prescription Form

Confidential facsimile transmission to:
CanadaEastPharmacy.com
Toll-free fax: 1 866 430 5481
Toll-free phone: 1 866 430 5480
www.CanadaEastPharmacy.com

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Prescriber's Name:	_______________________________________________________
Clinic Name:	_______________________________________________________
Prescriber's Address:	_______________________________________________________
Prescriber's Telephone:	_______________________________________________________
Prescriber's Fax Numer:	_______________________________________________________

Patient's Full Name:	_______________________________________________________
Patient's Address:	_______________________________________________________
Patient's Address:	_______________________________________________________

Rx # 1
Qty:
Sig:

Refill:

Rx # 2
Qty:
Sig:

Refill:

Prescriber Certification:

This prescription represents the original of the prescription drug order.
The pharmacy addressee noted above is the only intended recipient.
The original prescription has been invalidated and securely filed.

Presciber's Name: _________________________
Prescriber's Signature: __________________________ Date: _____________
DEA Number: _____________ License Number: ___________