Order Form

 
Step 1: Complete and sign the Order Form on the Signature lines at the bottom of Each page.

Step 2: Fax to Toll Free 1-877-372-7479, along with your original Prescription and a copy of a Picture ID. Make sure your doctor’s DEA number, license and phone # is written on prescription. If you do not have your prescription, have your doctor or pharmacy fax it to us. If cannot fax, please mail to: cpd pharmacy, 532 42 Avenue South East Calgary, Alberta, Canada T2E 7T1.

Medication including strength Please Print or Type Accurately (Maximum of 90 days supply of each medication can be shipped at any one time) Directions Qty. Generic Allowed (Y/N) # Refills
(No. or PRN)
         
         
         
         
         


PATIENT INFORMATION: (Please Print or Type Accurately) Please Check:
 
New Customer
 
Existing Customer
It is mandatory that you have had a complete physical examination in the past 12 months. Have you had one:
 
YES
 
NO
Check One:
 
Send my medicine in Original Manufacturers Container, which may not be childproof
 
Send my medicine in vial, which is childproof & is not in original container

 

Name (For Pet medication(s) Please Enter the Owner's Info!): ________________________________________

Address: ___________________________________________________________________________________

City: ________________________ State: _________ Zip: ____________ Employer or a Group ____________

Tel # (Day): __________________________________ Tel # (Night) :_________________________________

Date of Birth: ______________________ Sex: _______ Weight: ________

How did you hear about us?_______________________________ E-mail: ______________________________

Do you have any allergies (including drug allergies)? _____ If Yes please list: ___________________________

Please list all medications you are currently taking here: ____________________________________________

___________________________________________________________________________________________


Please Circle Any Medical Conditions that apply to you: Blood Disorders, Cancer, Immune disorders, Poor wound Healing, Neurological disorders, Diabetes, thyroid, or other endocrine disorders, Nutritional deficiency, Lipid or cholesterol disorder, Heart disease, Renal or kidney disease, Liver Disease, Orthopedic or Muscle disorders, Emotional disorders, Glaucoma.

If you circled any of above, please elaborate here:

__________________________________________________________________________________________

PRESCRIBING PHYSICIAN INFORMATION:   Name: _____________________________________________

Address: ________________________________________________________ DEA#: ____________________

City: _______________________________________ State: _______ Zip: ___________ Tel: ______________


CREDIT CARD BILLING INFORMATION:

Credit Card # ____________________________ Exp. Date: __________ Cardholder's Tel: _______________
(Visa and MasterCard Only)

Cardholder's Address: ________________________________________________________________________


________________________ _______________________ __________
CARDHOLDER'S NAME (print name) CARDHOLDER'S SIGNATURE DATE