Standard Referral Form 
Cochlear Implant Surgery Information
Tinnitus Questionnaires
Vertigo Questionnaire and ENG Lab Map
Surgery Information Sheets and Forms
 Meclizine Prescription Information

Synergy Pharmacy 
 Meclizine 25 mg TID PO tablets.

 #153, 501 Bethel Drive, Sherwood Park, AB T8H 0N2

 Tel: 780-449-2017 F: 780-449-6025


Heritage Wellness Pharmacy
Meclizine 25 mg TID PO tablets

10839-23 Avenue, Edmonton, AB

Tel: 780-485-3111  F: 780-485-3113
Audiology Referral Form