Customer Order Form
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STEP 1: Complete this order form (please print). Sign where required.
STEP 2: Fax or mail the order form along with a copy of your original prescription(s) and photo ID.
Fax completed form to:
FAX # 1-877-214-9620

or mail order form to:  Canada Pharmacy Store
#800, 15355 24th Avenue, Suite 551, Surrey, B.C. Canada V4A 2H9
PATIENT INFORMATION
Toll free phone: 1-888-786-1414 
First Name   Last Name    Male Female
Address Line 1  
Address Line 2  
City   State    Zip     
Phone   -   -   Alternate Phone    -   -  
Email  
  Date of Birth
 
  /   /  
MM   DD   YYYY
 
PATIENT MEDICAL INFORMATION   CREDIT CARD AUTHORIZATION
Physician Name  
Phone   -   -   Ext   
Fax    -   -    
Do you have any drug allergies? Yes No
If yes, please list here:  
 
 
 Please list all medications you are taking:
Medication & Strength
(eg. Lipitor 10mg)		 Doseage
(eg. 1 per day)		 Taking how long?
(eg. 2 years)
     
     
     
     
     
     

Check all medical conditions that apply to you:
arthritis lipid or cholesterol disorder
blood disorder renal or kidney disease
cancer liver disease
immune disorder orthopedic or muscle disorders
poor wound healing emotional disorders
neurological disorder glaucoma
diabetes chemical dependency
nutritional deficiency thyroid disorder
heart disease other endocrine disorders
Please elaborate on above conditions:  
 
 

NOTE: To avoid delays in processing, please speak to your credit card company and let them know that an international purchase will be going through on your credit card, and that they should authorize this purchase.
 
Card
number		   -   -   -  
VISA
Master Card
 

CCV  location   
Expiry Date    /   (MM/YY)   CCV  

Credit card billing address (if different than above)
Address  
City  
State   Zip   

I hereby authorize the pharmacy to apply applicable charges to my credit card for the cost of prescription drugs as noted on this order form including subsequent requested refills. In addition, I understand that a flat-rate shipping fee of $15.00 U.S. applies to each order, unless shipped together to the same address.

Printed Name   
     
Cardholder Signature   Dated

 



Canada Pharmacy Store

 PATIENT AGREEMENT Page 2 of 3
BY SIGNING BELOW I CONFIRM THAT:
 
1. IF PLACING THIS ORDER AS A CUSTOMER, I, ON BEHALF OF MYSELF, MY HEIRS, ASSIGNS AND SUCCESSORS, HEREBY AGREE TO ALL OF THE FOLLOWING TERMS AND CONDITIONS, REPRESENT THAT I UNDERSTAND ALL OF THE FOLLOWING TERMS AND CONDITIONS AND THAT I HAVE HAD ADEQUATE OPPORTUNITY TO CONSULT ANY ADVISORS NECESSARY, WHETHER MEDICAL, LEGAL OR OTHERWISE.
 
2. IF I AM PLACING THE ORDER ON BEHALF OF SOMEONE ELSE, I REPRESENT THAT I HAVE ALL NECESSARY CONSENT, PERMISSION AND AUTHORIZATION TO DO SO ON BEHALF OF THAT PERSON AND THEIR HEIRS, ASSIGNS AND SUCCESSORS AND THE PERSON I REPRESENT AGREES TO ALL OF THE FOLLOWING TERMS AND CONDITIONS, UNDERSTANDS ALL OF THE FOLLOWING TERMS AND CONDITIONS AND HAS HAD AN ADEQUATE OPPORTUNITY TO CONSULT ANY ADVISORS NECESSARY, WHETHER MEDICAL, LEGAL OR OTHERWISE.

AUTHORIZATION AND CONSENT
I hereby appoint Canada Pharmacy Store ("CPS") as my agent for the purposes of obtaining a prescription from a Medical Doctor in Canada (the "Canadian MD") which corresponds to the prescription included in this order, which may include directly contacting my prescribing physician, and assisting with the purchase and delivery arrangements of the medications prescribed in the Canadian prescription, substantially on the terms set forth below, all to the same extent I could if I personally took such steps. I hereby consent to CPS, the Canadian MD and any Pharmacy supplying my order, collecting my personal and medical information, maintaining the information necessary to quickly process future orders which may include retaining on file my name, address, phone number, payment and other information and verifying future orders. I confirm that my personal information will be handled in accordance to the Privacy Policy as posted at www.Canada Pharmacy Store.com's website which may be updated from time to time.

DISCLOSURE AND REPRESENTATIONS
I represent that all of the following statements are true and agree IHS is relying on these representations:
1. I am nineteen years of age or older.
2. I can make my own medical decisions according to the law of the place I reside.
3. The US prescription I am sending to CPS was prescribed by a qualified physician licensed where I obtained the prescription.
4. The prescription I am sending to CPS has not been altered in any way nor has it been filled prior to submission to CPS.
5. I agree to immediately destroy all copies of my prescription once it has been filled.
6. The laws in my geographical location permit the delivery of the requested medications(s).
7. I will use any medication shipped by the Pharmacy strictly according to the instructions provided by the Pharmacy.
8. I am placing this order for medication for my sole personal use and I will not provide any quantity of this medication to any other person.
9. I am not seeking or relying on any medical information from CPS and I have consulted a qualified physician licensed where I obtained the prescription within the last year.
10. I understand that I can contact a pharmacist if I want to discuss the benefits, side-effects, and risks of my medication.
11. I will immediately contact my physician who provided my US prescription included with this order in the event I suffer any unexpected side effects from any medication obtained for me.
12. I have answered truthfully all the medical questions on page 1 section entitled “Patient Medical Information”.
13. I hereby warrant that I am not taking any medications including non-prescription drugs or combination of medications other than those medications which I've indicated I'm currently taking on page 1 section entitled "Patient Medical Information".
14. I fully understand that it is my responsibility to have an annual physical examination, including any suggested laboratory testing to ensure that I have no diseases(s) that might make the medications inappropriate for my condition.

PURCHASE AND SALE TERMS
The Pharmacy will charge my credit card the following amounts: the medication price and shipping fee as posted at
www.Canada Pharmacy Store.com's website on the day CPS receives my order. In the event my payment is not authorized, we has the right to cancel my order and attempt to provide me with notice of such cancellation. CPS reserves the right to refuse to assist me in obtaining any order in its sole discretion, in which event I will be entitled to a refund for monies paid for such order. If requested on this order form, the Pharmacy will fill prescriptions using un-opened manufacturer original containers, but may from time to time open the manufacturers container to fullfil the prescriptions specified quantities. CPS does not provide its agent or attorney services as a substitute for health care or the advice of a physician. All prices quoted on the web site are subject to change without notice. CPS will not honor any typographical errors concerning price, strength, or dosage. The Pharmacy will only fill up to a 3 month supply of medications based on your prescription(s) regardless of the quantity written on this order form.

RELEASE AND WAIVER
I hereby release and discharge CPS and its employees, officers, agents, and representatives harmless from any and all suits, demands, liabilities, claims, actions, expenses, losses and damages of any kind or nature whatsoever, including, without limitation, general, direct, special, indirect and consequential damages and costs of litigation (including reasonable attorney fees) arising from:
 
1. My use of the medication ordered for me by CPS and dispensed by a registered pharmacy, including, without limitation, any and all side effects whether previously known or unknown
2. CPS's manner or timeliness of completing any actions I have authorized above, including, without limitation, their manner or timeliness in prescribing the appropriate strength, or dosage;
3. My breach of any terms, conditions or representations or warranties in this agreement; and
4. Nothing in this release shall be deemed to release any Pharmacy or pharmacist from compliance with the applicable standards of practice or usual professional duties and obligations, which a pharmacist owes.
 
GOVERNING LAW
This agreement, along with any disputes that may arise, will be governed by and construed in accordance with the laws of the Province of British Columbia, Canada. I have read and understood all of the foregoing terms and conditions.  
              
Patient name (print)        Patient signature   Dated


Canada Pharmacy Store

 Printed 11/21/08   Page 3 of 3
REQUESTED MEDICATIONS  
QUANTITY MEDICATION STRENGTH GENERIC BRAND
     
     
     
     
     
     
     
Note: Unless stated on your US prescription or specified by you, generic substitution will be filled as per pharmacy laws in British Columbia.
         Due to current regulations, we can only ship a maxiumum 3 month supply of any medication.

 PACKAGING OPTIONS
Ship my medications with easy open, snap cap lids Automatically process my refills and send them without contacting me first. (We will still call to counsel on meds.)
Ship medications with child proof lids. For care homes: Package meds in 30-day bubble pack cards when possible. ($3.00 charge per medication per month)
Ship medications in original sealed manufacturer’s container, which may not be childproof and may contain a desiccant which should not be swallowed. (We will adjust your requested quantity to match the manufacturer container quantity.)  

 PATIENT COUNSELLING INFORMATION
This is my first time using at least one of the medications listed above
Please have a pharmacist call me regarding information about my medication

 HOW DID YOU FIND US? (optional) JN000
Internet search Television Magazine Doctor
Newspaper Radio Friend/Family Other________________
 
COPY OF YOUR PRESCRIPTION FROM YOUR DOCTOR AND PHOTO ID

Please place copies of your prescription

and valid ID here or on separate pages.

Optional pieces of identification can be any of the following:
 
  • drivers licence
  • birth certificate
  • state medical card
  • other photo ID.