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Office Use Orders - TrioLab

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Office Use Orders Form

Health Care Professional Name:

License Number:

Provincial Jurisdiction: SelectAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon

Health Profession:

Clinic Name:

Mailing Address:

Medication/Device Names:

Quantity:

Contact Phone Number:

Message

*All Orders will Be verified by phone by our pharmacy team.
*Trio Compounding Lab & Pharmacy reserves the right to reject any order.