Ordering Your Prescription
Fill out the Patient Questionnaire section and fax your order to 1-866-91-DRUGS. Any information you provide will remain confidential and a chart will be created for you and kept by the Canadian licensed physician.
Patient Information
Your prescription must be co-signed by a Canadian licensed physician. In order to do this you will be required to complete a patient questionnaire. The Canadian physician may contact you or your physician with questions.
Review
The medical questionnaire will be reviewed by the Canadian physician.
Approval and Shipping
Once the Patient Questionnaire and prescription have been reviewed by the Canadian physician he/she will either approve your prescription or request more information. Once approved your medication will be shipped to you. The United States Food and Drug Administration (FDA) currently limits the quantity of a personal prescription mailed to a resident in the United States to a 3 month supply. Every 3 months you can order a refill of your medications provided that the prescription that you submitted to Canadian Pharmacy Network allows the refills. Once the refills have been exhausted then you will need to submit a new prescription. If there have been no changes to your prescription we will not require another patient questionnaire. If there are no changes to your health or medication you will be required to submit a patient questionnaire annually only.
Your charges will include:
1) Drug cost as quoted by our staff.
2) Shipping / Handling / Postage fee of $15.00 U.S. per shipment
** Please keep in mind that your order will take between 3 and 4 weeks for you to receive provided that there are no problems with your order.
Please Include:
1) Your prescription
2) Your Patient Questionnaire and Release form - (pages 2 to 5) plus your prescription(s)
Filling out the questionnaire should only take a few moments of your time but it is very important to do so. It will enable us to safely and efficiently approve and fill your prescription. This in turn will enable you access to high quality prescription medications but at the much lower Canadian prices. If you have found our prescription service helpful tell a friend! Thank you.
Please Be Advised
We DO NOT ship controlled substances such as narcotics, amphetamines, benzodiazepines (e.g. Valium) and feel that we can best serve your needs if we concentrate on providing you with maintenance medications such as: high blood pressure, diabetes, arthritis, cholesterol medications etc.
Not all prescription drugs available in the U.S.A. are available in Canada. We make generic substitution wherever possible to maximize your savings. Any generic drug dispensed has been approved for substitution by the Canadian Health Protection Branch.
Return Policy
Prescriptions are not returnable. All sales are final sales.
Contact Us
Please call us at 1-866-90-DRUGS with any questions you have.
General questions Email: info@canadianpharmacynetwork.com
Please keep this page for your records. You do not need to fax or mail this page
Complete form and fax to: 1-866-91-DRUGS
- 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.
- 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 CANADIAN PHARMACY NETWORK. ("CPN") and its delegates or contractors as my agent and attorney for the purposes of obtaining a prescription from a Medical Doctor in Canada (the " Canada MD") which corresponds to the prescription included in this order, which may include directly contacting my prescribing physician, and purchasing and arranging delivery 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 CPN, the Canada 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 only by CANADIAN PHARMACY NETWORK order-processing employees and contractors (including physicians and nurses, pharmacists and pharmacy technicians) according to the Privacy Policy as posted on the CPN Website (www.canadianpharmacynetwork.com) which may be updated from time to time.
Disclosure And Representations
* I represent that all of the following statements are true and agree that CPN and its contractors (physicians and nurses, pharmacists and pharmacy technicians) are relying on these representations:
- I am of the age of majority or older where I reside;
- I can make my own medical decisions according to the law of the place I reside;
- The prescription I am requesting CPN to assist me in obtaining was prescribed by a qualified physician licensed where I obtained the prescription;
- The prescription I am requesting CPN to assist me in obtaining has not been altered in any way nor has it been filled prior to submission to CPN. I agree to immediately destroy all copies of my prescription once it has been filled;
- I am not violating any laws where I reside by placing this order;
- I will use any medication obtained for me by CPN strictly according to the instructions provided by the physician who prescribed the medication;
- I am placing this order for medication for my sole use and I will not provide any quantity of this medication to any other person;
- I am not seeking or relying on any medical information from CPN and I have consulted a qualified physician licensed where I obtained the prescription within the last year; and
- I will immediately contact the physician who provided my prescription included with this order in the event I suffer any unexpected side effects from any medication obtained for me by CPN.
Purchase And Sale Terms
* The Canadian pharmacy will charge my credit card the following amounts: the medication price (in US dollars.) as posted on the CPN Website on the day CPN receives my order, SHIPPING COST for each package CPN ships and any applicable taxes. * In the event my payment is not authorized, CPN has the right to cancel my order and attempt to provide me with notice of such cancellation. * CPN 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. * CPN does not provide its agent or attorney services as a substitute for health care or the advice of a physician. * CPN will not exchange medication or return any monies paid once an order is filled, unless the medication provided to me by the supplying pharmacy does not correspond with my prescription.
Release And Waiver
* I hereby release and save CPN and its employees and contractors (including physicians and nurses, pharmacists and pharmacy technicians) 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:
- my use of the medication obtained for me by CPN including, without limitation, any and all side effects whether previously known or unknown;
- Canadian PHARMACY NETWORK or its contractors' manner or timeliness of completing any actions I have authorized above, including, without limitation, their manner or timeliness in prescribing the appropriate strength, dosage, or dispensing generic drugs and non-child-protective packaging; and
- my breach of any terms, conditions or representations or warranties in this agreement.
Governing Law
* This agreement, along with any disputes that may arise, will be governed by and construed in accordance with the laws of Canada.
I have read and understood all of the foregoing.
_____________________________ |
_____________________________ |
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| Patient's Signature | Patient's Name (Print Clearly) | Date |
Complete form and fax to: 1-866-91-DRUGS
Contact Information
| First Name | Last Name | Address | ||
| ( ) | ( ) | |||
| City | State | Zip | Phone | Fax |
Patient Information
| Male/Female | Lbs | ||
| Gender | Weight | Date of birth (MM/DD/YYYY) | Occupation |
Physical Exam
| Check this box if you have had a physical examination in the last 12 months: Yes, I have. |
Current Medication
| Medication/Illness Diagnosis | |
| 1) | 6) |
| 2) | 7) |
| 3) | 8) |
| 4) | 9) |
| 5) | 10) |
Family Medical History
| Diabetes, Thyroid or other endocrine disorder Cardiovascular (Heart or Artery disease) Hypertension (High Blood Pressure) Lipid (cholesterol) disorder |
Breast Cancer Prostate Cancer Other forms of cancer Migraine Headaches |
Other Illnesses
| Please list any other family illnesses not previously noted: |
_________________________________________
________________________________
Note: All pages of this document must be signed and dated in order to be processed.
Complete form and fax to: 1-866-91-DRUGS
Please complete all applicable fields.
Patient Medical History
| Blood Disorders Cancer Immune Disorders Poor Immune Healing Edema or excessive fluid retention Neurological disorders Thyroid, diabetes or other endocrine disorder Any known nutrition deficiency Hyperlipidemia (High Cholesterol) Upper respiratory disorder Smoker Lung disorder (i.e. asthma, emphysema) High Blood Pressure Heart Disease (Including atherosclerosis, angina, heart failure or history of) |
Renal or Kidney disease Liver disease Drug allergies Orthopedic or muscle disorder (Including fracture, joint disorder or carpal tunnel syndrome) Emotional disorders Surgery Glaucoma Chemical dependency Rheumatoid arthritis Lupus Connective tissue disorders Other illness not noted Regular Exercise Medications used in the last 12 months |
If you answered yes to any of the above questions please elaborate in the box below
(I.e. duration of illness, any treatment of surgery received, amount smoked and how long):
_________________________________________
________________________________
Note: All pages of this document must be signed and dated in order to be processed.
Complete form and fax to: 1-866-91-DRUGS
Please complete all applicable fields.
Order Details
| Medication | Strength | Quantity | RX | Price |
| Yes No | ||||
| Yes No | ||||
| Yes No | ||||
| Yes No | ||||
| Yes No | ||||
| Yes No | ||||
| Shipping | 15.00 USD | |||
| Total | ||||
Shipping Information
| Address | ||
| City | State | Zip |
Payment Method
| Visa MasterCard |
Credit Card Information
| Card Holder Name | Credit Card Number | Expiry Date |
| Address | ||
| City | State | Zip |
Do you want us to use generic drugs to fill your order and save you even more money? Yes No
I hereby waive my right to pharmacy counseling, as I have previously been counseled Yes No
Please do not contact me regarding this order, rather ship medication described above Yes No
I understand that all prices quoted and charges to my credit card will be in U.S. Dollars Yes No
In case where refills are prescribed would you like Canadian Pharmacy Network to mail you the refill order and charge your credit card for the drug cost plus shipping. Yes No
_________________________________________
________________________________
Note: All pages of this document must be signed and dated in order to be processed.
Complete form and fax to: 1-866-91-DRUGS
Toll free help line: 1-866-90-DRUGS
Return by mail to: 2498 West 41st Ave., Suite #111, Vancouver, B.C., V6M 2A7, CANADA
Or fax to: 1-866-91-DRUGS
You may copy this complete document and give it to friends or family
Attach Prescription Here (Please ensure that we can see the entire prescription) Please use one page per prescription Print extra copies of this page if you have additional prescriptions. |