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RX REFILLS & TRANSFERS

PRESCRIPTION REFILL

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What prescription would you like to get filled?

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Prescription Number/ Medication Name

Prescription Number/ Medication Name

Prescription Number/ Medication Name

Prescription Number/ Medication Name

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Additional Notes

PRESCRIPTION TRANSFER

TRANSFER - JOIN US AT URBAN PHARMACY

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Transfer all prescriptions OR

RX Number/ Medication Name

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URBAN PHARMACY

900 Rathburn Rd W Unit B4,

Mississauga, ON L5C 4L3

905-897-2210

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