Wellness & Performance Refill

Easily pick a convenient time and date for the health practitioner to call and discuss your medical request.

Patient Full Name*
First Last
Shipping Address for Prescription
Street Address Address Line 2 City Province Postal Code
Email*
Best Contact Phone Number*
Appointment Request*
Please choose the type of follow-up appointment you require. Payment will be requested via Interact E-Transfer.
Please upload any medical documents in regards to your appointment request
Drop files here or

Accepted file types: jpg, gif, png, pdf, Max. file size: 80 MB.
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Appointment Request
Please indicate the type of appointment you
Additional Information
Please add any additional information that you would like the health practitioner to know about before your appointment
What prescription are you requesting for refill ?
Payment will be requested when our health practitioner approves your refill and a copy will be sent to you via email.
Prescription Service Charge
Price:
Payment will be requested via Interact E-Transfer ONLY when a prescription is approved and authorized.
Total
$ 0.00 CAD
All payments are requested by Interact E-Transfer.