Patient Information

Affiliate #
Form #1


License #32599
Toll Free Phone 1-800-640-2221
7 - 2 Donald Street
Winnipeg, MB Canada R3L 0K5
Toll Free Fax 1-800-640-5553
www.cantrustrx.com

Complete this form and fax or mail it along with:

1) Original Prescription 2) Medication Order Form 3) Release Form

The Patient Information Form and Release form only need to be submitted with first order.

First Name:____________________________ Last Name:___________________________________

Address: ____________________________________________________________________

City:__________________________ State:__________________ Zip Code:__________________

Home Phone:( )_______________ Work/Day Phone:( )__________________

Fax: ( )___________________ E-mail________________________________________

Date of Birth:__ /__ /__ (mm/dd/yy) Weight: _________ Sex: o male o female

Secondary Contact: _________________________________Phone: ( )_____________________

Relationship:_____________________________

Your Doctor’s Information:

Name:_______________________ Address:______________________________________

Phone: ( ___)__________________ City, State: _________________________________

Known Drug Allergies:

Medication
____________________________________
____________________________________
____________________________________

Reaction
____________________________________
____________________________________
____________________________________

Current Medications:

Please list all medications you are currently using.

Drug Name

Strength

Directions

How long using

Drug is used to treat

Example drug

5mg

1 tablet twice a day

2 years

diabetes

1.

 

 

 

 

2.

 

 

 

 

3.

 

 

 

 

4.

 

 

 

 

5.

 

 

 

 

6.

 

 

 

 

7.

 

 

 

 

8.

 

 

 

 


Patient Signature:_____________________________Date:__________________

Referred by:______________________________________Address:____________________________