Patient Allergy/Interaction Form

Original Prescriptions must accompany this form - faxed or mailed in.

( * Required information )

Name: *			Date of Birth: *
Address:			City:
			State:
			ZIP:
Home Phone: *			Work Phone:
Fax:			Email: *

Medication Required	Strength	Quantity	Price/US








Shipping & Handling Charges			$15.00
Total Amount

I hereby waive my right to pharmacy counseling, as I have been previously counseled regarding the above
medications. (Optional)

Please do not contact me regarding this order, but rather ship the medication as described above. (Optional)

Payment Method

Visa Mastercard Diner's Club Certified Cheque

Name:		Credit Card #
		Expiry Date:
		Today's Date:

How to Order:

Click on the Submit button below to Order online and make sure that Patient's Questionnaire, Patient Release Form and Prescriptions are submitted to us prior to submitting this Order form.

Or

You may print this Order Form and Fax or Mail it to us at the above specified address.

RxmedsCanada.com 22 -11440 Braeside Drive SW Calgary AB T2W 3N4 Canada Tel: (403) 238 - 9535 Fax: (403) 238 - 0858 Toll Free Phone: 1 (888) 209 - 0411 Toll Free Fax: 1 (888) 209-7099
Print the Form	Home Page	Back to Forms