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 PRINT THESE FORMS


5 SIMPLE STEPS TO START SAVING

1
  The first step of the process is to Complete the Patient Profile.
2
  Complete the Order Form.Make sure to date and sign the Order Form.
3
  Complete the User Agreement.Make sure to date and sign the User Agreement Form.
4
  Gather your Doctorís Prescriptions along with the Completed Forms. Please make cheques/money orders payable to GLENWAY PHARMACY.
5
  Send or Fax Completed Forms along with your Doctorís Prescriptions to:


  Mail ††
P.O. Box 50089
660 Eglinton Ave. East
Toronto, Ontario,
Canada
M4G 2K0
  Toll Free Fax
1-866-497-9782


 
 





A representative will contact you when we receive your information.




Patient Profile

 

Your Full Name_______________________Date of Birth____________________

Address______________________________ Height_________________________

City_________________________________ Weight_________________________

State/Province_________________________ Sex___________________________

Zip/Postal Code________________________Country________________________

Phone Number††† (††††† ) _________________

Spouse or other person's name if you want packages shipped together____________

Have they previously filled out a Questionnaire?____________________________


Primary Physician's Name______________________________________________
Address_____________________________________________________________
Phone (††††† )_____________________    Fax (†††††† )__________________________

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/dosage

Direction for use

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Please list all known allergies___________________________________________________________
_______________________________________________________________________________________

 

 






 

 

Patient Profile Ė Contíd

 

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
Immune disorders
Poor wound healing
Edema or excessive fluid retention
Neurological disorders
Hyperlipidemia(high cholesterol)
Upper respiratory disorders, ears, nose, throat
Smoker
Lung disorder (i.e., asthma, emphysema)
Emotional disorders, stress
Surgery
Glaucoma
Chemical dependency
Other illness not yet noted
Medications used in the past 12 months
High blood pressure

Renal, bladder or kidney disease
Liver disease

Drug allergies


Orthopaedic/Muscle disorder, fracture, joint disorder or carpal tunnel syndrome
Thyroid,diabetes or other endocrine disorder, including insulin resistance
Heart Disease angina, chest pains, palpitation, heart failure or history of heart attack

Any known nutrition deficiency including minerals and electrolytes
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. (i.e. duration of illness, any treatment or surgery received, amount smoked and for how long?) ________________________________________________________________________________________________________________________________________________

 



 




Order Form

 

Medication Ordered

Dosage

Quantity

Generic

Price in US Dollars

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

†††††††††††††††††††††††††††††††† †††Shipping Charge:  †††††††† $12.00 US

†††† Total:   $___________US

 

 CREDIT CARD INFORMATION

 

Cardholder (name on card) ___________________________________________ 

Cardholder address_________________________________________________
Credit card number_________________________________________________  

Cardholder city____________________________________________________
Credit card expiry___________________________________________________

Visa ††††††††MasterCard







 

††† Mailing Address

††††††††††††††††††††††††††††† P.O. Box 50089

†††††††††††††††††††††† 660 Eglinton Avenue East

Toronto, Ontario

††††† Canada

†††† M4G 2K0 

 

 

 

*Money orders are the preferred method of payment. Personal cheques are accepted but must clear before processing will begin. This may add up to 7 days to the shipment times. ( No third party cheques accepted.)

Please make out all personal cheques and money orders to GLENWAY PHARMACY

*Note in order to order from the Canadian Licensed Pharmacy you must have been on the medication for a minimum of 30 days.

Informed consent for Patient Counseling:
The pharmacy will 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
Would you like a pharmacist to call you to discuss your medication __yes ___no


Signature:______________________________ Date:_______________________

























User Agreement Form

(No prescriptions will be filled without a signed 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 the pharmaceutical(s) ordered by the Patient ("the Ordered Product") were prescribed by a duly qualified medical practitioner in the place of residence of the Patient. 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. By reviewing the Patientís medical information, the Canadian Physician is not providing any service or advice to the Patient.The Patient confirms that they did not request a medical opinion of the Canadian Licensed co-signing Physician regarding the Ordered Product. The Patient agrees to direct all questions to The Patientís Physician. The Patient will consult The Patientís Physician before taking any new drug, natural product, or changing their daily health regiment.

4. The Canadian Licensed Pharmacy 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 Patientís Physician conduct regular physical examinations (minimum every 12 months), including any and all suggested testing by The Patientís 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 Patientís 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 agrees to release and discharge The participating Canadian Licensed Pharmacy and all of its Employees & Contractors, including the Doctors and Pharmacists, from all liability, claims, or causes of action with respect to any side effects, the appropriateness, suitability, strength or dosages of the pharmaceutical(s) prescribed for the undersigned.

6. The Patient understands and acknowledges that the Ordered Product(s) will not be packaged in child protective
packaging. The Patient assumes all responsibility for safe and secure storage, restricting non-patient access to the
medications.

7. The Patient releases and discharges the Canadian Licensed Pharmacy, its contractors and its Employees from any and all causes of action with respect to the late delivery, non-delivery or missed delivery of the Ordered Product(s) sent to the Patient. 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.

8. The Patient grants Limited Power of Attorney to Canadian Licensed Pharmacy, for the limited purpose of signing any documents as required by the laws of the Province of Manitoba (Canada), or Ontario (Canada), 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 personally attended the pharmacy in Winnipeg, Manitoba, Canada.

9. The Patient agrees that any dispute that arises between Him or Her and the Canadian Licensed Pharmacy shall be heard by the courts of Manitoba, Canada. The courts of Manitoba, Canada shall have the sole and exclusive jurisdiction, and that the laws in force in Manitoba, Canada, shall apply to any and all disputes that may arise.

10. The Patient must honestly report all requested information and immediately update any changes to his or her record.

11. The Patient understands that the Ordered Product may not be exchanged or returned for a 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.
 Name: __________________________†††† Date: ___________††† Signature:_________________________