Pharmacy

We are pleased to offer you the convenient option to contact Rao Dermatology regarding pharmacy concerns regarding patient care, without the need to fax or telephone.This is, by far, the FASTEST means to contact our office regarding a prescription. Only if you must, use the traditional means of contacting our office by faxing us: 780-437-2247.

The Pharmacy Request Form below MUST be filled out by a Pharmacy and MUST be authorized by a Canadian-licenced pharmacist. The information you submit is secure and confidential, and will be forwarded only to Dr. Rao’s office for processing.

Patient Information

First Name*:

Last Name*:

Patient Phone Number:

Date of Birth*:

Gender*:

Pharmacy Information

Pharmacy Name*:

Pharmacist Name:

Pharmacy's Office Phone*:

Pharmacy's Office Fax:*

Notes

Notes*:

Upload Files

Upload Document #1 (Eg. Scan or Image under 2MB):

Upload Document #2 (Eg. Scan or Image under 2MB):

Authentication Information

Name of person completing this form*:

Statement of Authenticity*: