Below is our online customer order form to fill out for safe and convenient delivery of your prescription drug needs through the internet. If you are new to our website and need further instructions for ordering online, please go to the "How to Order" page for full directions. Or if this is your first time refilling an order online, you too can go to the "How to Order" page for instructions on reordering.

Personal Information

Click the button below if this order is for a pet?


Payment Information

For maximum security on Credit Card transactions, we ask our clients please call toll free 1-866-247-2323 between 8:00am and 6:00pm CST Monday to Friday, and one of our staff will collect your information to ensure a safe & secure transaction and answer any questions you may have about your purchase.

 

First Time Customers

Attach Prescription or submit it separately by scanned email or fax to our toll free fax

Attach a scanned prescription (optional) 2MB maximum

Upload input

Medication (optional)

Product list

  • Generic?
  • Generic?

  • Generic?
  • Generic?

  • $15.00
Check this box if you DO NOT want child proof caps

The products mentioned are trademarks of their respective owners and are not owned by or affiliated with Canada Rx Connection or any of its associated companies. All prices quoted are in US dollars.

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