**Fax Cover Sheet - CanadaMeds.com**
Thank You For Submitting Your Order
Your information has been sent directly to our Pharmacy. The final step is to print this page, fill out the information below, and fax it to us as a cover page to complete your order.
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Prescription Order Fax Cover Page
Fax Number: 1-877-994-2121
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| Total Number of Pages (including this sheet) |
| Your Name: (as written on prescription) |
| Is this your first order with us? Yes No |
| Address: |
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| Home Phone: |
| Birth Date: |
| Number of Prescriptions In This Order: |
Please Attach Prescription to the Box Below Before Faxing:
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