Canadian Prescription Savers

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NEW PATIENTS

EXISTING
PATIENTS

Mailing Address:
916 West Broadway
Suite 700
Vancouver, BC, Canada
V5Z 1K7

Toll Free Phone:
1-800-PILLS-81
(1-800-745-5781)

Toll Free Fax:
1-800-PILLS-41
(1-800-745-5741)

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Placing your order online is a simple 3 step process:

	Requirements for submitting your information online Before continuing to our secure online order form, you need to confirm you have a working printer.
	Fill out your "Personal Health Profile" using our online form Before we can send you medication, our physicians require you to provide personal health information.
	Print, sign, and send us the required "Customer Agreement" We are required to have a signed customer agreement before we can send you medication. Please print, sign, and either fax or mail us our "Customer Agreement" form.

PART 1: GENERAL PATIENT INFORMATION

First Name: Initial: Last Name:

Street Address:

City: State: Zip: -

Date of Birth: / / Sex:

Height: ,

Weight: (in pounds)

Home Phone:

Work Phone:

(If Available)

Fax Number:

(If Available)

Email Address:

Please note: It is mandatory to have had a physical examination in the last 12 months.
Have you had one?

Do you get regular exercise?

Please indicate any known drug allergies or adverse reactions you may have had in the following box:

Have you previously filled out a questionnaire with Canadian Prescription Savers?

If yes to above, have there been any changes to your patient Questionnaire?

PART 2: MEDICATION(S) CURRENTLY BEING TAKEN

Please list all medications you are currently using, including the dosage and frequency:

	Medication	Dosage	Frequency

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PART 4: ADDITIONAL QUESTIONS

On orders where refills are prescribed, I agree to contact Canadian Prescription Savers 21 day 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:

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 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:

PART 5: MEDICATION(S) BEING ORDERED

Where available, please use generic drugs to save me more money:
* 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.

YOUR ORDER:

	Medication	Dosage	Quantity

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Click here to double check prices

PART 6: PAYMENT INFORMATION

Please select your method of payment:

Visa: Mastercard: Personal Check

* Your credit card will not be charged until we've receieved your signed Customer Agreement and Prescription(s) (further info below)

If your paying by credit card please complete the following information:

Card Holder Name:

Credit Card Number:

Card Holder Street Address:

Card 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: