PATIENT PROFILE
Enter your Contact Information and primary address: (Please Print Clearly)
* First Name:		Middle Name:
* Last Name:		* Gender:	Male Female
* Date Of Birth:	Day              Month             Year	* Weight (lbs):
* Primary Address:		* City/Town:
		* State:
* Zip Code:		* Country:
Email:
* Phone (Home):		Phone (Work):
Fax:		Phone (Cell):
Shipping Instructions:
Shipping Address (if different than the address above) NOTE: Your primary address (above), if this is the only address given, or your separately stated shipping address (below) will be used as the "ship to" address for your prescription orders. The address you provide will be used for all future orders unless and until you notify us that your shipping address has changed.
Shipping Address:		City/Town:
		State:
Zip Code:		Country:

Check all the medical conditions that you “currently” have:
Alzheimers Disease	Epilepsy	Liver disease
Anxiety	Glaucoma	Osteoporosis
Arthritis - Rheumatoid, Osteoarthritis & Lupus	Heart disease (please describe)	Parkinsons Disease
Asthma	High blood pressure	Schizophrenia
Cancer (please describe)	HIV / AIDS	Thyroid disorders
COPD - Bronchitis & Emphysema	Hysterectomy	Tobacco use (do you smoke?)
Depression	Kidney or renal disease	Diabetes (please describe)
High Cholesterol
Please use the space below to add additional comments regarding the medical conditions you have selected above and/or other medical conditions not listed.

Drug Allergies: Please check the drug group and circle the corresponding medication.
A.C.E. Inhibitors (Vasotec, Altace, Zestril, Accupril, Capoten)	Glucocorticoids (Prednisone, Cortisone, Dexamethasone)	Penicillins (Amoxil, Ledercillin VK, Ampicillin, Augmentum)
Beta Adrenergic Blocking Agents (Inderal, Tenormin, Sectral, Betapace	Histamine H2 Inhibitors (Zantac, Tagamet, Pepcid)	Proton Pump Inhibitors (Aciphex, Nexium, Protonix, Prilosec, Prevacid)
Calcium Channel Blocking Agents (Norvasc, Diltiazem, Verapamil, Plendil, Nifedipine)	HMG-COA Reductase Inhibitors (Lescol, Zocor, Pravachol, Lipitor, Mevacor)	Quinolones (Cipro, Noroxin, Levaquin)
Carbamazepine (Tegretol)	Hydantoins (Phenytoin, Dilantin)	Selective Serotonin Reuptake Inhibitors (Prozac, Zoloft, Luvox, Celexa, Paxil)
Cephalosporins (Keflex, Ceclor, Cefzil, Ceftin)	Macrolides (Biaxin, Erythromycin, Zithromax)	Sulfonamides (Bactrim, Septra, Cotrim, Celebrex, Flomax, Glyburide, HCTZ)
Cox-2 Inhibitor (Vioxx, Celebrex, Bextra, Mobic)	NSAID's (Naprosyn, Aspirin, Relafen, Voltaren, Indocid, Motrin)	Tetracyclines (Tetracycline, Minocycline, Doxycycline)
Please use the space below to add additional comments regarding the allergies you have selected above and/or other allergies not listed.

Order and Existing Prescriptions
Please list below any medications you are currently taking, how long you have been taking them and the conditions for which they have been prescribed: (*If applicable)
Drug Name/Strength	Length Used (Example: 5 years)	Medical Condition (Example: high cholesterol)	Order Today?
1)			Yes No
2)			Yes No
3)			Yes No
4)			Yes No
5)			Yes No
6)			Yes No
7)			Yes No
8)			Yes No
9)			Yes No
10)			Yes No
NOTE: We will only send a 90-day supply in the original manufacturers package or less if requested AND available in original manufacturer's package. ** All sales are final. We cannot accept the return of any medications. To minimize waiting time, please ask your physician to write the prescription for a 3-month supply plus 3 refills. Your initial order for each prescription will be delivered between 14 and 21 days in most cases. All refills should be delivered in approximately 10 days.
* Please use Generics to save more money:		Yes No
* Please use Childproof lids on containers:		Yes No
* How will you get the original Prescription to us?		I will fax the Prescription to you The Physician will fax the Prescription I will send the original Prescription to the Pharmacy by mail

Payment Options
We offer two forms of payment: Credit Card (Visa or Mastercard) and check. Please check which option you prefer and fill in the required information.
Option 1: CREDIT CARD		Option 2: PAY BY CHECK
* Card holder’s name:		* Account holder’s name:
* Credit Card Type:	Visa / MasterCard (circle one)	* Bank Account Number:
* Credit Card Number:		* Bank Routing Number:
* Expiration Month:		* Driver’s License Number Or Mother’s Maiden Name:
* Expiration Year:
* Cardholder's Signature:
In respect of your order, billing information will appear on your bank/credit card statements as follows: for any prescriptions purchased from/dispensed by our Canadian pharmacy, a charge will appear on your bank/credit card statement as a charge from “Extended Care Pharmacy”; and for any prescriptions purchased from/dispensed by a non-Canadian pharmacy, a charge will appear on your bank/credit card statement as a charge from “Rx-Payments.com”. Remember – if you order your prescriptions both from our Canadian pharmacy and from a non-Canadian pharmacy or pharmacies, you will have multiple charges on your bank/credit card statement (one for each country you are purchasing your prescriptions from).
Canadian Doctor Declaration I provide my consent to allow a physician licensed in Canada to obtain my medical history, drug history, contact information and other necessary documentation from my U.S. physician. In this context, I further consent to both the Canadian physician and my U.S. physician being able to contact one another to discuss my medical condition, as it pertains to the prescribing of the medication(s) in question. I understand that the reason for this consent is to provide the Canadian physician with a full opportunity to conduct an independent analysis of whether the medication(s) prescribed by my U.S. physician is appropriate, and discuss any potential medical complications that may arise. I further understand that my medical information will not be used for any other reason, and will be kept in strict confidence. I further agree to regularly visit my U.S. physician(s) and to promptly advise the Canadian physician of any changes to my medical condition or prescriptions.
Counselling Information We offer counselling to all of our patients about the prescription medications we provide. We also ensure that these consultations will be conducted in an atmosphere of confidentiality and privacy. A consultation is designed to provide you, our patient, with important information regarding your prescription medications. A consultation will cover the drug name, what the drug does, how and at what time the drug should be taken, drug interventions, the importance of taking the drug as directed (regularly or when needed), what to do if a dose is missed, common side effects, food, drink or other activities to avoid, special storage requirements and refill information. Would you like a pharmacist to contact you regarding any of these issues or any other drug related question? Yes____ No____

 

Attach a copy of your original prescription here!

* * * IMPORTANT * * * We require that the full patient name, address (and telephone number) must be CLEARLY PRINTED on the written prescription in order for this prescription to be filled.

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