Medication Order

Affiliate #

Form #3

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) Patient Information Forms ___3) Release Form

Drug Name	Strength	Directions	Quantity	Price
Example drug	10mg	1 tablet 3 times a day	300	$00.00
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Shipping and Handling: There will be a $14.00 shipping fee per household				$14.00
Total (all amounts are in US dollars)

Billing Information:

Please input the EXACT credit card billing information, or your order will be delayed.

Type of card: Visa O Mastercard O American Express O

Cardholder’s Name: ___________________________________________

Credit Card Number: ___________________________________Expiry Date:_____/_____

Address to send receipt to:_____________________________________________

_____________________________________________

As a member of the Manitoba Pharmaceutical Association, we pledge to keep all of our clients well informed about the prescription medications we provide. We also ensure that these consultations will be conducted in an atmosphere of confidentiality and privacy. These consultations are designed to provide you, our clients, with important information regarding your prescription medications.

This information includes:

The drug name What to do if a dose is missed The importance of taking the drug as directed, regularly or when needed ? Food, drink, other drugs or activities to avoid

What the drug does Common side effects How and at what time the drug should be taken Refill information Special storage requirements

A reminder to please consult your doctor or pharmacist before taking any medication not prescribed by your doctor.

To confirm that you have read the above, please sign and date below:

Patient signature:___________________________________ Date:_________________