Once you have completed the Patient Health Profile and the Order Form please attach the original prescription and fax the documents to our toll free fax number: 1-866-366-5381
Please note: it is mandatory to have had a physician’s examination in the last 12 months. Have you had one?_______________________________________________________
Please list all medications you are currently using, including the dosage and frequency.
Medication Name
Strength/Dose
Directions for use
Please list all known Allergies ________________________________________________
Patient Profile
Patient Name ______________________________________________________
Patient medical history Do you have a history or early finding suggestive of the following? (Please check all that apply) Blood disorders Cancer Poor wound healing Edema or excessive fluid retention Neurological disorders Thyroid, diabetes or other endocrine disorder, including insulin resistance Any known nutrition deficiency including minerals and electrolytes Hyperlipidemia (high cholesterol) Upper respiratory disorders, ears, nose, throat Smoker Lung disorder (i.e., asthma, emphysema) High blood pressure Heart disease including arteriosclerosis, angina, chest pains, palpitation, heart failure or history of heart attack Renal, bladder or kidney disease Liver disease Drug allergies Orthopedic or muscle disorder, including fracture, joint disorder or carpal tunnel syndrome Emotional disorders, stress Surgery Glaucoma Chemical dependency Other illness not yet noted Medications used in the past 12 months Rheumatoid arthritis, lupus, or connective tissue diseases Regular exercise What type, frequency and duration of exercise _______________________________ ______________________________________________________________________ If you checked any of the above questions, please elaborate below. (ie., duration of illness, any treatment or surgery received, amount smoked and for how long?) ______________________________________________________________________ ______________________________________________________________________
Order Form
Medication being ordered
Strength/Dose
Quantity
Generic substitution
Price (US$)
*We are required to dispense pills in child resistant containers unless indicated*
Easy off caps
Shipping Charge: $10.00 US Total: $___________US
Credit card information
Cardholder(name on card) _________________________________________________
Credit card city _______________________________________________________
Cardholder state _________________________________________________________
Cardholder zip code ______________________________________________________
Visa MasterCard Amex
*Note in order to order from CanadaRx you must have been on the medication for a minimum of 30 days.
Informed consent for Patient Counseling:
We provide patient counseling from a licensed pharmacist on all prescriptions. This includes:
1. Medication identification (name, dose and use) 2. Directions for use and what to do if you miss a dose 3. Drug or food interactions and common side effects 4. Special storage requirements and refill information
When would you like a pharmacist to call you to discuss your medication?
No prescriptions will be filled without a signed and dated copy of this form
The undersigned, (hereinafter the "Patient") confirms that:
1. The Patient is of the age of majority in the jurisdiction, in which the Patient resides and is fully competent to make their own health care decisions. 2. The Patient confirms that a duly qualified medical practitioner in the place of residence of the Patient prescribed the pharmaceutical(s) ordered by the Patient (“the Ordered Product”). The Patient has not violated any laws in obtaining the prescription and that the Ordered Product will not be used by no other person and in no manner except as prescribed by the original prescribing physician ("The Patient's Physician"). 3. The Patient agrees to direct all questions to The Patient's Physician. The Patient will consult The Patient's Physician before taking any new drug, natural product, or changing their daily health regiment. 4. CanadaRx.com requires the patient to submit a new medical questionnaire every time there is a change to their medical status. The Patient understands that it is their responsibility to have The Patient's Physician conduct regular physical examinations (minimum every 12 months), including any and all suggested testing by The Patient's Physician to ensure that they have no medical problems which would constitute a contradiction to them taking medications prescribed for them. The Patient agrees that should they suffer any adverse affects while taking any prescription medication that they will immediately contact The Patient's Physician and that in the event they come under the care of another physician, the Patient will inform this physician of any and all medications that have been prescribed. 5. The Patient must take responsibility to secure their own medication stock from a local pharmacy in the interim if such an event was to evolve, ensuring that at no point they are without medication. 6. The Patient grants Limited Power of Attorney to CanadaRx.com, for the limited purpose of signing any documents as required by the laws of the country in which CanadaRx.com is registered in, which are necessary to permit the delivery of the Ordered Product to the Patient, in the same manner as the Patient could, if the Patient had attended CanadaRx.com's physical location in person. 7. The Patient agrees that any dispute that arises between Him or Her and CanadaRx.com shall be heard by the local courts of the country to which CanadaRx.com is registered to and located in. These courts shall have the sole and exclusive jurisdiction, and that the laws in force in the country to which CanadaRx.com is registered to, shall apply to any and all disputes that may arise. 8. The Patient must honestly report all requested information and immediately update any changes to his or her record. 9. The Patient understands that the Ordered Product may not be exchanged or returned or refund once purchased and shipped.
BY SIGNING THIS DOCUMENT THE PATIENT CONFIRMS THAT HE OR SHE HAS READ AND UNDERSTOOD EACH OF THE ABOVE TERMS AND HAS AGREED TO EACH ONE.