1. ENTER INFORMATION ABOUT YOUR LAST VISIT TO YOUR PHYSICIAN

Have you seen a physician in the last 12 months?

Yes No
 

2. ENTER YOUR PERSONAL DETAILS

First Name

 

Middle Name

 

Last Name

 

Your Gender

Male Female

Your Birth Date

Month Day Year

Your Weight

in Pounds

 

3. ENTER YOUR CONTACT INFORMATION AT YOUR PRIMARY ADDRESS

Street

City/Town

State

Zip Code

Country

Phone (Home)

Phone (Office)

(optional)

Phone (Cell)

(optional)

Fax

(optional)

Email

 

4. ENTER YOUR CONTACT INFORMATION AT YOUR ALTERNATE ADDRESS IF APPLICABLE

Street

City/Town

State

Zip Code

Country

Phone (Home)

 

5. ENTER YOUR SHIPPING PREFERENCE

Where would you like this order shipped ?

Primary Address   Alternate Address

Please provide any other shipping information ?

(optional)

 

6. ENTER INFORMATION ABOUT YOUR PRIMARY PHYSICIAN

First Name

Last Name

Street

City/Town

State

Zip Code

Country

Phone

Fax

(optional)

 

7. ENTER YOUR PERSONAL MEDICAL HISTORY

1)

Blood disorders

Yes   No

2)

Cancer

Yes   No

3)

Immune disorders

Yes   No

4)

Poor wound healing

Yes   No

5)

Neurological disorders

Yes   No

6)

Diabetes, thyroid or endocrine disorders

Yes   No

7)

Known nutrition deficiency including minerals or electrolytes

Yes   No

8)

Lipid or cholesterol disorder

Yes   No

9)

Heart disease including atherosclerosis, angina, heart failure or history of heart attack

Yes   No

10)

Renal or kidney disease

Yes   No

11)

Liver disease

Yes   No

12)

Orthopedic or muscle disorder, including fracture, joint disorder or carpal tunnel syndrome

Yes   No

13)

Emotional disorders

Yes   No

14)

Surgery

Yes   No

15)

Glaucoma

Yes   No

16)

Hyperlipidemia (high cholesterol)

Yes   No

17)

Chemical dependency

Yes   No

18)

Upper respiratory disorders

Yes   No

19)

Smoker

Yes   No

20)

Lung disorder (i.e. asthma, emphysema)

Yes   No

21)

Rheumatoid arthritis, lupus, or connective tissue diseases

Yes   No

22)

High blood pressure

Yes   No

23)

Other illness not listed above

Yes   No

If you answered YES to any of these questions, please explain further

 

8. ENTER YOUR PRESCRIPTION PREFERENCE

Would you like the Canadian Physician to prescribe a generic alternative if it is available?

Yes   No

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.

How will you get the copy of the original prescription to us?

I will fax the prescription
Physician will fax the prescription
I will send the prescription by mail
 

9. ENTER YOUR ALLERGY INFORMATION

Do you have any drug allergies?

Yes   No

If Yes, please list below and describe the reactions:

 

10. ENTER YOUR CURRENT MEDICATIONS

Please list ALL medications you are currently taking and the conditions for which they have been prescribed.
Indicate with a yes or a no, if you would like to order this particular medication at this time.

Medication Name

Strength

Directions for use

How long have you been taking this drug?

Quantity Requested

Order this Medicine
Yes or No

Example Drug Name

70mg

1 tablet a day

8 months

90 Tablets

YES

Note: The pharmacy will send you a 90-day supply unless otherwise specified. It is generally cheaper to get a 90-day supply.

To minimize waiting time, please ask your physician to write the prescription for a 3-month supply plus 3 refills. Your initial order for each prescription will be delivered between 14 and 21 days in most cases. All refills should be delivered in approximately 10 days.

 

11. READ OUR RETURN POLICY

All sales are final. Be sure you order accurately to prevent problems. The law states:
"A pharmacist shall not accept for return to inventory any drug that has been previously dispensed"

Pharmaceutical Act Section 23(1) Return Medication (1)

I have read and understand the information above:

Yes   No
 

12. ENTER YOUR BILLING INFORMATION

Cardholder's Name

Credit Card Type

Credit Card Number

Expiration Date

Month

Year


A Representative will call you to confirm your order after successfully completing your order forms

If You have any questions, please call toll free 1-866-712-4448

** You will be charged in US Dollars **
We do accept Money Orders & Personal Checks - Please make payable to Glenway Pharmacy