You have chosen to fax the Legal Disclaimer, and Patient Questionnaire to CanTrustRx. Please select one of the two available download formats:

• Print from the web as one document or print each page: Page 1 | Page 2 | Page 3 | Page 4
• Download the Legal Disclaimer and Patient Questionnaire (PDF Format)
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• Download the Legal Disclaimer and Patient Questionnaire (Microsoft Word Format)

Fax or Mail us your prescription, "Legal Disclaimer" and "Patient Questionnaire" forms.

If you do not have your original or a copy of your prescription, please provide CanTrustRx with your physician's name, telephone and fax number. Our staff will contact your doctor directly and request a copy of the prescription.

Fax:
1-800-640-5553

Mail To:
CanTrustRx Pharmacy
7 - 2 Donald Street
Winnipeg, Manitoba
Canada
R3L 0K5