CANADIAN PRESCRIPTION SAVERS
PERSONAL HEALTH PROFILE
Please provide all requested information. Any omissions may delay the processing of your order.


PART 1: GENERAL PATIENT INFORMATION

_________________________________________________________________________________________
Full Name
_________________________________________________________________________________________
Street Address
____________________________
City		____________________________
State		_____________________________
Zip
____________________________
Date of Birth (Day/Month/Year)		__________
Age		__________
Sex		_________________
Height		_________________
Weight
____________________________
Home Phone		____________________________
Work Phone (if available)		_____________________________
Fax Number (if available)
Please note: It is mandatory to have had a physical examination in the last 12 months.
Have you had one? Yes ___ No ___ (Answer Required)

Do you get regular exercise? Yes ___ No ___ (Answer Required)

Please indicate any known drug allergies or adverse reactions you may have had on the following lines:
_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________
Have you previously filled out a questionnaire with Canadian Prescription Savers?
Yes ___ No ___ (Answer Required)

If yes to above, have there been any changes to your Patient Questionnaire? Yes ___ No ___

PART 2: PATIENT MEDICAL HISTORY
Please list all medications you are currently using, including the dosage and frequency:

1. [ ] Blood disorders
2. [ ] Lipids (Cholesterol)
3. [ ] Cancer
4. [ ] Immune disorders
5. [ ] Poor immune healing
6. [ ] Edema or excessive fluid retention
7. [ ] Neurological disorders
8. [ ] Thyroid, diabetes or other endocrine disorder,
including insulin resistance
9. [ ] Hyperlipidemia (high cholesterol)
10. [ ] Upper respiratory disorders
11. [ ] Smoker
12. [ ] Lung disorder (i.e., asthma, emphysema)
13. [ ] Heart disease including arteroisclerosis, angina,
heart failure or history of heart attack
14. [ ] High blood pressure

15. [ ] Urinary, Renal or kidney disease
16. [ ] Gastro Intestinal(Stomach,Liver, Intestines)
17. [ ] Drug allergies
18. [ ] Orthopedic or muscle disorder, including fracture
joint disorder or carpal tunnel syndrome
19. [ ] Emotional disorders
20. [ ] Surgery
21. [ ] Glaucoma(Eye)
22. [ ] Chemical dependency
23. [ ] Rheumatoid arthritis, lupus, or connective tissue
diseases
24. [ ] Dermatological Problems
25. [ ] Other:__________________________________
26. [ ] Other:__________________________________
27. [ ] Other:__________________________________
If you have had any surgeries or answered yes to any of the above questions please elaborate below: (i.e., duration of illness, any treatment or surgery received, amount smoked and for how long.)
_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________
Please check all which apply to members of your family

1. [ ] Diabetes, Thyroid or other endocrine disorder
2. [ ] Cardiovascular (Heart or Artery disease)
3. [ ] Hypertension (High Blood Pressure)
4. [ ] Lipid (cholesterol) disorder

5. [ ] Breast Cancer
6. [ ] Prostate Cancer
7. [ ] Other forms of cancer
8. [ ] Migraine Headaches


PART 3: MEDICATION(S) CURRENTLY BEING TAKEN
Please check all which apply to you:
Medication                 Dosage    Frequency

1)_________________ ________ __________

2)_________________ ________ __________

3)_________________ ________ __________

4)_________________ ________ __________

5)_________________ ________ __________
 Medication                 Dosage    Frequency

6)_________________ ________ __________

7)_________________ ________ __________

8)_________________ ________ __________

9)_________________ ________ __________

10)________________ ________ __________

PART 4: ADDITIONAL QUESTIONS
Please list all medications you are currently using, including the dosage and frequency:

On orders where refills are prescribed, I agree to contact Canadian Prescription Savers 21 days in advance of refill
due date to ensure an uninterrupted supply of medication and I understand no refills will be shipped without
contacting Canadian Prescription Savers: Yes [ ] No [ ] (Answer Required)

All patients receiving prescriptions from a Canadian Pharmacy have the right to receive certain information:
Medication identification (what it is and what it is used for), Dosage regimen (when and how to take the medication), Compliance and missing doses (the importance of using the medication correctly and what to do if a dose is missed), Drug/drug and drug/food interactions (foods and medications, prescription and over the counter which may interact with the medications currently being taken), Side effects and precautions (common side effects as well as rare side effects), Proper storage (for medications with special storage instructions), Refill information (how many refills are remaining if any)

Would you like a pharmacist to call to discuss this with you: Yes [ ] No [ ] (Answer Required)

Where available, please use generic drugs to save me more money: Yes [ ] No [ ] (Answer Required)
* Canada has one of the highest standards in the world for generic drug manufacturing and testing. Our rigorous approval system has ensured the highest quality drugs at the lowest prices for Canadians for many years. You too can enjoy the savings of our world-class generic drugs.

I have included a photocopy of Picture ID or two pieces of Secondary ID: Yes [ ] No [ ] (Answer Required)

PART 5: MEDICATION(S) BEING ORDERED

Medication Name

 Dosage (Strength) Quantity
________________________________ ___________________ ____________
________________________________ ___________________ ____________
________________________________ ___________________ ____________
________________________________ ___________________ ____________
________________________________ ___________________ ____________
________________________________ ___________________ ____________
________________________________ ___________________ ____________
________________________________ ___________________ ____________
________________________________ ___________________ ____________
________________________________ ___________________ ____________
________________________________ ___________________ ____________
     
    Shipping:
    Total:


PART 6: PAYMENT INFORMATION

Please select your method of payment:     Visa ________ Mastercard _______ Personal Check _______

If paying by credit card please complete the following information:

_____________________________________
Card Holder Name (on card)		_____________________________________
Credit Card Number
___________________________________________________
Card Holder Street Address		____________________
Expiry (MM/YY)
____________________________
City		____________________________
State		_____________________________
Zip




I hereby authorize Canadian Prescription Savers to charge my credit card for the medications ordered
plus any associated shipping and handling charges

____________________________________
Signature		____________________________
Date Signed



PART 7: CUSTOMER AGREEMENT
I confirm the following information and provide the following release

1. I hereby state that I am of the age of majority in the jurisdiction where I ordinarily reside and I am fully competent to make my own health care decisions.

2. I state that I have had a physical examination by the physician whose care I am under within the last twelve months and I understand that it is my responsibility to have regular physical examinations by the U.S. licensed physician whose care I am under including all suggested testing by said physician to ensure I have no medical problems, which would constitute a contradiction to me taking the medications being prescribed for me.
3. I will only use the medication as prescribed by a duly qualified medical practitioner

4. I will not allow anyone else to use the ordered medication.

5. I acknowledge I may not return any medication dispensed to me.

6. I am not seeking medical advice or treatment of any kind whatsoever from Canadian Prescription Savers Ltd. or it's
affiliated pharmacy, or the Canadian licensed co-signing physician and I am dealing with Canadian Prescription Savers Ltd. and it's affiliated pharmacy for the sole purpose of obtaining medication at a lower price than my home country.

7. I hereby acknowledge that my personal doctor originally prescribed the prescription I wish to obtain.

8. I release and discharge Canadian Prescription Savers Ltd. and it's affiliated pharmacy, including all of its employees
and contractors including pharmacists, pharmacy technicians, physicians, nurses, and receptionists from any and all liability whatsoever associated or connected to the use of any and all of the medications prescribed to me and including but not limited to any adverse effects I may suffer from these medications.

9. I understand the risks of taking medication and I understand that all of the possible risks and/or complications that may occur may have never been recorded before.

10. By signing this waiver I agree to release liability and hold harmless the issuing pharmacy, physicians, directors, officers, employees, representatives, and independent contractors from all causes of action, suits, penalties, liens, judgments, liabilities, obligations, losses, actual or consequential damages and actual or threatened claims which may arise at any time by reason of relating to, arising directly or indirectly out of any matter whatsoever related to the prescribing or dispensing of my prescription medications.

11. I acknowledge that the physicians and pharmacists working on my behalf are located and licensed to practice medicine and/or operate a pharmacy in Canada and that all treatment that I am receiving from the said physician and pharmacists is received in Canada.

12. I agree to the jurisdiction of the province in Canada in which the pharmacy resides and where the prescription was issued, where the Pharmacy provider maintains its offices, meaning that any disput that arises between the providing Pharmacy and me will be governed by the laws of that Province in Canada where the pharmacy is located and any applicable federal laws of Canada; and

13. If any dispute does arise between Canadian Prescription Savers Ltd. or its affiliated pharmacy its pharmacy provider and me about rights or liabilities arising from the purchase of my medication that cannot be resolved on the basis of both sides acting reasonably, then such dispute shall be referred to arbitration in the province of Canada in which the pharmacy resides.This agreement represents the complete and entire agreement between Canadian Prescription Savers Ltd. and its affiliated pharmacy, affiliated agents and me. I have read and understood the above-referenced "Customer Agreement Form". I declare that I understand all the terms and conditions herein.



_______________________________
Patient's Signature		______________________________
Patient's Name (Print Clearly)		__________________________
Date (Day/Month/Year)