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Patient Information |
Affiliate # |
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Form #1 |
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Complete this form and fax or mail it along with:
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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:
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:
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Medication |
Reaction |
Current Medications:
Please list all medications you are currently
using.
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Drug Name |
Strength |
Directions |
How long using |
Drug is used to treat |
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Example drug |
5mg |
1 tablet twice a day |
2 years |
diabetes |
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Patient Signature:_____________________________Date:__________________
Referred by:______________________________________Address:_____________________________
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Patient Information |
Affiliate # |
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Form #2 |
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Please answer the following
questions by circling Yes or No
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Yes |
No |
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Yes |
No |
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Yes |
No |
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Yes |
No |
Personal Medical History:
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Cancer |
Y __N |
Liver disease |
Y __N |
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Immune disorders |
Y __N |
Anxiety |
Y __N |
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Poor wound healing |
Y __N |
Depression |
Y __N |
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Lung disorders (Asthma,COPD,Emphysema) |
Y __N |
Other emotional disorders |
Y __N |
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Upper respiratory disorders |
Y __N |
Parkinsons |
Y __N |
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Smoker |
Y __N |
Epilepsy |
Y __N |
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High blood pressure |
Y __N |
Schizophrenia |
Y __N |
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Heart disease (incl. Arteriosclorosis, angina heart failure, or history of heart attack) |
Y __N |
Other neurological disorders |
Y __N |
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Hyperlipidemia (high cholesterol) |
Y __N |
Thyroid disorder |
Y __N |
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Glaucoma |
Y __N |
Diabetes |
Y __N |
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Known nutritional deficiency (incl. Minerals or electrolytes) |
Y __N |
Other endocrine disorders |
Y __N |
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Chemical dependency |
Y __N |
Recent surgery |
Y __N |
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Rheumatoid Arthritis, Lupus, or connective tissue diseases |
Y __N |
Past surgery |
Y __N |
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Orthopedic or muscle disorder (incl. fracture, joint disorder, or Carpal tunnel syndrome) |
Y __N |
Renal or kidney disease |
Y __N |
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Blood disorders |
Y __N |
Other illness not listed above |
Y __N |
If you
answered yes to any of the above questions, please explain further:
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Patient Signature:___________________________________ Date:____________________
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Medication Order |
Affiliate # |
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Form #3 |
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Complete this form and fax or mail it along with:
1) Original Prescription ___2) Patient Information Forms ___3) Release Form
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Drug Name |
Strength |
Directions |
Quantity |
Price |
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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 |
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Total (all amounts are in US dollars) |
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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:_____________________________________________
_____________________________________________
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As a member of the Manitoba Pharmaceutical Association, we pledge to
keep all of our clients well informed about the prescription medications
we provide. All 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: |
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To confirm that you have read
the above, please sign and date below:
Patient signature:___________________________________ Date:_________________
A reminder
to please consult your doctor or pharmacist before taking any medication not
prescribed by
your doctor.
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CanTrustRx Inc. Limited Power of Attorney & Release Form |
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No prescription will be filled until a
signed and dated copy of this document and a completed Patient Questionnaire
has been received by CanTrustRx Inc. These documents can sent be fax toll
free to [1-800-640-5553] THE UNDERSIGNED, BEING OVER THE AGE OF 21,
HEREBY: 1.
Represents and
confirms CanTrustRx Inc., along with its subsidiaries and affiliates (herein
collectively "CanTrust") that the pharmaceutical(s) to be delivered
to the undersigned were prescribed by a doctor licensed to practice medicine
in the country, state, or other applicable jurisdiction in which the
undersigned resides, that the prescription(s) for the pharmaceutical(s) were
lawfully obtained from that physician and that the pharmaceutical(s) will be
used only as directed and only by the person for whom the pharmaceutical was
prescribed. 2.
Acknowledges
that CanTrust and CanTrust’s employees and agents have relied on the
information and documentation provided by the undersigned (including the
Patient Questionnaire) and the undersigned represents and confirms that the
undersigned has, to the best of his/her knowledge, fully disclosed all
pertinent requested information and documentation to CanTrust. The
undersigned undertakes to notify CanTrust of any changes to his/her physical
or medical condition by providing an updated Patient Questionnaire. 3.
Understands that
it is the undersigned’s responsibility to have regular physical examinations
by the U.S. licensed physician whose care he/she is under, including all
suggested testing by said physician to ensure the undersigned has no medical
problems, which would constitute a contradiction to him/her taking the
medication(s) being prescribed. 4.
Authorizes and
appoints CanTrust, as his/her agent and his/her attorney for the limited
purposes of taking all steps and signing all documents on behalf of the
undersigned necessary to obtain a prescription in Canada for the prescription
sent by the undersigned to CanTrust, to the same extent as the undersigned
could do if he/she were personally present taking those steps and signing
those documents himself/herself, including, but not limited to, collecting
personal health information regarding the undersigned directly from his/her
prescribing physician or pharmacist and disclosing personal health
information to CanTrust employees, agents and service providers, as required,
for the limited purposes set out above. 5.
Authorizes and
appoints CanTrust as his/her agent and his/her attorney for the purpose of
taking all steps and signing all documents on behalf of the undersigned
necessary to package or repackage the pharmaceutical(s) and to deliver them
to the undersigned, to the same extent as the undersigned could do if he/she
were personally present taking those steps and signing those documents
himself/herself. 6.
Authorizes and
appoints CanTrust, as his/her agent and as his/her attorney for the purpose
of taking all steps and signing all documents on behalf of the undersigned
for shipping his/her prescribed pharmaceutical(s) to the undersigned as if
the undersigned had shipped the prescribed pharmaceutical(s) to
himself/herself to the undersigned’s address.
7.
The undersigned releases and discharges
CanTrust and CanTrust’s employees and agents, from any and all causes
of action with respect to the late delivery, non-delivery or missed
delivery of the pharmaceutical(s) sent to the undersigned. 8.
Acknowledges and
agrees that the undersigned initiated a consultation with CanTrust and that
CanTrust is not located in the 9.
Acknowledges and
agrees that any and all agreements reached or contracts formed throughout the
course of the relationship between the undersigned and CanTrust shall be
deemed to be made in 10. Agrees that any dispute that arises between him/her
and CanTrust, its affiliates, related companies, subsidiaries, parent
company, officers, directors, employees or agents shall be governed by the
laws of the Province of Manitoba and the laws of Canada applicable to
contracts formed in Manitoba and the undersigned agrees that the Courts of
the Province of Manitoba shall have sole and exclusive jurisdiction over any
such dispute. 11. Understands that CanTrust shall be entitled to substitute
a prescription drug with a generic drug, where available in accordance with
the Manitoba Drug Standards and Therapeutics Formulary, unless the physician
has indicated that there be "no
substitution". 12. Acknowledges and understands that once purchased and
shipped, no pharmaceutical product may be returned or exchanged. THE UNDERSIGNED HAS
READ AND UNDERSTANDS THESE TERMS AND AGREES THAT THEY SHALL BE BINDING UPON
THE UNDERSIGNED AND HIS/HER HEIRS, SUCCESSORS AND PERSONAL REPRESENTATIVES Patient Signature: _______________________________________________
Print Patient Name: _______________________________________________ Date Signed: _______________________________________________ According to provincial regulations all pharmaceuticals WILL be packaged in Childproof containers unless refused by checking (or circling) NO below: _______ NO |