Toll-Free Phone: 1-866-600-9222
Toll-Free Fax: 1-866-600-9333
Send completed FORM with your PRESCRIPTION and PAYMENT by toll free fax 1-866-600-9333
or mail to North Drug Mart, 1054 Centre Street, Suite 320, Thornhill, Ontario, Canada L4J 8E5

Patient's Information (Shipping Address)
Full Name:
Date of Birth:   Gender: Female Male     Weight:   Height:
Street Address:
City: State: Zip Code:
Phone:   Alternate Phone:
Email Address:

Medications You Are Ordering

Ordering from North Drugmart is easy and affordable! We make every effort possible to provide you with the lowest priced options for filling your prescriptions.
Medication & Strength QTY Generic
Allowed (Y/N)		 Price
       
       
       
       
       
       
S&H $10.00
Total

Credit Card Information And Authorization

TO PAY BY CASHIERS CHECK or MONEY ORDER, mail payment and order to the appropriate address (see page 3).
Please make payment to North Drugmart. If you have any questions regarding payments, call toll-free 1-866-600-9222
Method Of Payment: MasterCard Visa Money Order/Cashier's Check
Card Number: Expiry Date:       CVV:
(last 3 numbers on back of card)
Cardholder's Signature: ___________________________________ Date Signed: _____________

Physician Information
Doctor's Name:
Doctor's Telephone:

Customer Health Information
Drug Allergies:


Medical History:

Current Medications
Please list below all prescription, otc, and alternative medications or supplements you are currently taking.
Medication & Strength Instructions (eg. 1/day) Time Used (eg. 5 years) Medical Condition (eg. cholesterol)


Would you like a pharmacist to call you to provide counselling?    Yes No

North Drugmart Consent and Waiver of Liability
1. I believe the medical history information provided to be true to the best of my knowledge. I, also, understand and acknowledge, North Drugmart, with my best interests in mind, may use and disclose the minimum information necessary for treatment, payment, or health care operations. This includes - planning my care and treatment, communication with other health officials who contribute to my care, billing operations, and assessing health care quality and reviewing the competence of health care professionals.

2. When filling my medications through North Drugmart’s Canadian and International pharmacies, I authorize North Drugmart to take all steps, sign all documents and to act on my behalf as if I were personally present and acting myself for the limited purposes of (a) obtaining a Canadian and/or International prescription for any prescription which I have sent North Drugmart; and/or (b) packaging my prescriptions and delivering them to me.

3. I am not seeking medical advice or treatment of any kind whatsoever in coming to North Drugmart and its physicians, employees, officers, agents and all others acting through or for it.

4. Neither North Drugmart, nor any of its physicians, employees, officers agents and all others acting through or for it, or anyone that is acting on its behalf, is providing medical advice, professional advice, treatment advice or treatment of any kind whatsoever to me.

5. I am coming to North Drugmart for the SOLE PURPOSE OF OBTAINING A PRESCRIPTION MEDICATION. I understand that no one on behalf of North Drugmart will take any steps whatsoever to determine whether the prescription is appropriate. Title to my medications passes from North Drugmart to me when my medications leave North Drugmart’s affiliated pharmacies.

6. I hereby acknowledge that this prescription was originally prescribed by an American doctor and that I will continue to have my medical condition and medications monitored by my doctor.

7. I have given the authority to North Drugmart to act as my agent and/or representative to facilitate the purchase of prescription medicine from licensed pharmacies, filled by licensed pharmacists.

8. In consideration of approving this prescription and in consideration of North Drugmart fulfilling this prescription, I agree not to sue North Drugmart, its employees, officers, agents and all others acting through or for it, and release North Drugmart, its employees, officers, agents and all others acting through or for it, from all legal liability for any problems associated with the prescription.

9. I hereby agree that the relationship between and the resolution of any and all disputes arising between me and North Drugmart, its employees, officers, agents and all others acting through or for it, shall be governed by and construed in accordance with the laws of the Province of Manitoba, Canada. I hereby acknowledge that the Courts of the Province of Manitoba shall have jurisdiction to entertain any complaints, demands, claims or cause of action, whether based on alleged breach of contract or alleged negligence arising out of the signing of this prescription, and I hereby agree that I submit irrevocably to the exclusive jurisdiction of the Courts of the Province of Manitoba.

This agreement shall apply to every sale by North Drugmart to me and may not be altered unless in writing and signed by both North Drugmart and me. I HAVE READ AND UNDERSTAND THESE TERMS AND AGREE THAT THEY SHALL BE BINDING UPON ME AND MY ASSIGNS, HEIRS AND PERSONAL REPRESENTATIVES. Order cancellation charge of $20.00 will apply to any order, once that order has been processed and before it has shipped. Medical history information on this form is effective on the date signed and shall expire in one year or when the information becomes inaccurate. I understand that I am ordering from an international pharmacy and that once the pharmacy ships my medications, ALL SALES ARE FINAL. We are unable to take returns. I understand that prices are SUBJECT TO CHANGE without prior notice. When placing an order, please call to receive current pricing.
Customer Signature: X____________________ Print Name Clearly: ____________________ Date: __________
Your Prescription Order

Attach Prescription(s) Here (print extra pages if required)
(Please ensure that we can see your entire prescription(s).)

Placing Your Order By Fax, Telephone

Placing Your Order By Mail

Ready to place your order? Simply FAX your form along with any prescriptions to our toll-free fax: 1-866-600-9333. Please contact us toll-free at 1-866-600-9222 about 30 minutes after faxing to confirm that we have received your order.

If you have any questions, feel free to contact us toll-free at
1-866-600-9222.

If you do not have access to a fax machine or are paying by cashier's check or money order, you have the option of mailing in your valid US physician's prescriptions.

North Drugmart
1054 Centre Street
Suite 320
Thornhill, Ontario
Canada L4J 8E5

NOTE: Please mail us your prescription after you have faxed or emailed it to us. We will process your first order immediately with the faxed prescription, however, we will require the original prescription(s) to send you refills. A fax from your doctor's office is considered an original prescription.