If you have had an appointment at the Newman Breastfeeding Clinic within the last 6 months and would like a refill of a medication one of our pediatricians prescribed to you or your baby, please fill out the request form below. A prescription refill charge of $10.00 is requested via Paypal.  The refill will be faxed directly to your pharmacy.  

 

If you have not had an appointment at the clinic in the last 6 months, we may not be able to provide a refill. Please email your request to admin@ibconline.ca.

Breastfeeding Parent's First Name (required)

Breastfeeding Parent's Last Name (required)

Baby's First Name

Baby's Last Name

Phone (required)

Email (required)

Date of Last Appointment at Newman Breastfeeding Clinic (required)

[ "date of last appointment"]

Medication Name (required)

Dose (required)

Your Pharmacy Name (required)

Your Pharmacy Address (required)

Your Pharmacy Fax Number (required)



Thank you! You will be redirected to Paypal to confirm the $10.00 fee for prescription renewal and contacted by email to confirm your prescription renewal.