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 *IT
IS MANDATORY THAT YOU HAVE HAD A COMPLETE PHYSICAL
EXAMINATION IN THE PAST 18 MONTHS.
HAVE YOU HAD ONE?
YES
NO
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*Would
you accept a generic brand drug to save even more money.
YES
NO |
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Prescriptions:
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1.
I
will fax or e-mail the scanned prescription(s)
to the pharmacy. |
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2.
My physician
will fax or e-mail the scanned prescription(s)
to the pharmacy.
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Physician's
Name:
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Physician's
Address:
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Telephone
Number:
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Fax
Number:
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3.
I will fax or e-mail the scanned prescription(s)
and mail you the original prescriptions
to your pharmacy
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Prescription
to be Filled: (Before
listing your medications please check the
RxMedscanada prescription make sure we stock
your medication. Remember that some drugs
have different names in Canada.)
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Please
list the medication that you are ordering,
with the quantity, dosage
and strength:
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How
many months supply
are you ordering?
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Patient
Information:
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First
Name: |
*
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Last
Name: |
*
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Email: |
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Street: |
*
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2nd
Street: |
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City/Town: |
*
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State: |
*
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Zip
Code: |
*
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Other
Territory: |
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Country: |
*
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Fax:
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Phone: |
*
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Sex:
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*
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Your
Weight in pounds: |
*
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Birth
Date: |
* |
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Patient
Family Medical History: |
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Patient
Personal Medical History: |
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Yes |
No |
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1).
Blood disorders |
*
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2). Cancer |
*
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3).
Immune disorders |
*
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4). Poor
wound healing |
*
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5).
Neurological disorders |
*
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6). Diabetes,
thyroid or other endocrine disorders |
*
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7).
Known nutrition deficiency including minerals
or electrolytes |
*
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8). Lipid
or cholesterol disorder |
*
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9).
Heart
disease including atherosclerosis, angina, heart
failure or history of heart attack |
*
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10). Renal
or kidney disease |
*
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11).
Liver disease |
*
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12). Drug
Allergies |
*
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13).
Orthopedic
or muscle disorder, including fracture, joint
disorder or carpal tunnel syndrome |
*
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14). Emotional
disorders |
*
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15).
Surgery |
*
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16). Glaucoma |
*
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17).
Hyperlipidemia
(high cholesterol) |
*
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18). Chemical
dependency |
*
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19).
Upper respiratory
disorders |
*
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20). Smoker |
*
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21).
Medications
used in the last 12 months |
*
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22). Lung
disorder (i.e., asthma, emphysema) |
*
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23).
Rheumatoid arthritis, lupus, or connective tissue
diseases |
*
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24). High
blood pressure |
*
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25).
Other illness
not listed
above |
*
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If
answered yes to any of these questions, please
explain further.
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Allergy
Information: |
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Do
you have any allergies (including drug allergies)? |
*
If so, Please list below.
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Current
Medications: |
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Please
list all medications you are currently taking and the
condition for which they have been prescribed for:
* (If applicable)
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