Mr

Mrs

Ms

Dr

Male

Female

___________________________________________________
First Name                                 Last Name

___________________________________________________
Street

___________________________________________________
City                                     State                            Zip Code

(          )____________________ (          )________________
Day Phone                                  Evening Phone

_______/_______/_______     _______    ______     _______
Birth Date (MM/DD/YYYY)         Age           Height      Weight

PAYMENT METHOD Choose how to pay for your order: VISA   Master Card   personal check   International money order   __________/ __________/ __________/ _________ Credit Card Number Expiry Date (MM/YY) ___________________________________________________ Cardholder’s Name ( as it appears on credit card ) ___________________________________________________ Cardholder’s Street Address ___________________________________________________ Cardholder’s City                          State                      Zip Code X_____________________________  (             ) ___________ Cardholder’s Signature                         Cardholder’s Phone #

YOUR Primary Physician

___________________________________________________
Physician’s Full Name

___________________________________________________
Address

___________________________________________________
City                                       State                   Zip Code

(          )___________________  (        )_________________
Phone                                         Fax

Free Prescription Request Service!  Yes  No Please contact my physician’s office on my behalf to request any prescriptions not included with this order be faxed directly to MedCenter Canada.

YOUR ORDER
Enter the medication, dosage, quantity and price of your drugs. Indicate if you'll allow generic substitution to save you money. Calculate the total amount in U.S. Dollars including shipping & coupons. Please allow 2 weeks for delivery.

MEDICATION	STRENGTH	QTY	GENERIC OK?	PRICE
			Yes  No	$
			Yes  No	$
			Yes  No	$
			Yes  No	$
			Yes  No	$
			Yes  No	$
			Yes  No	$
			Yes  No	$
			Yes  No	$
			Yes  No	$
			+ Shipping	FREE
			Total

PATIENT COUNSELING Under Manitoba law, all patients have a right to patient counselling.What is a convenient time for the pharmacy to call you regarding patient counselling? ______a.m / p.m. CHILD-PROOF CAPS ? All pill bottles will have child-proof caps unless you check “No”.  No

DRUG ALLERGIES ? Do you have any drug allergies?  Yes  No If yes, please list the drug(s) and their allergic reaction: __________________________ __________________________ __________________________ __________________________ __________________________ __________________________

MEDICATION	STRENGTH	FREQUENCY