Prescription Order Form
Please complete and fax this form toll-free 1-866-327-8364
 
Patient Information

33 Coldwater Crt.
Thornhill, Ontario, L4J 7S4

Phone Toll Free 1.866.817.5145
Phone Local 1.416.217.2727

Fax Toll Free 1.866.327.8364
Fax Local 1.416.217.0199

info@canadianpharmacychoice.com
www.canadianpharmacychoice.com

First Name___________________________________

Last Name____________________________________

Membership Code______________________________

Ship To   ∅Patient   ∅Physician   ∅Caregiver/Parent/Guardian

Name (If Not Patient)________________________

Address______________________________________

City___________________State_________Zip__________

Telephone____________________________________

Email________________________________________
Payment Information
 
Method (Check One)   ∅Check/MO   ∅Master Card   ∅Visa
 
By Check:

Name (as on check)________________________

Address (as on check)_____________________

City_________________State______Zip_______

Telephone_____________________________

 By Credit Card:

Credit Card Number_________________________

Expiry Date____________MM_______YY_____

Card Holder Name___________________________

Medication (Including Strength) Dosage (Directions) QTY. Brand (B) Generic (G) # Refills (No. PRN) Cost
           
           
           
           
           
           
  Shipping: $9.95
Total:  
Special Instructions
 
  ∅ Send my medication in the original container, which may not be childproof
  ∅ Send my medication in a vial, which is childproof and is not the original
 
 
 
  Authorization
 

33 Coldwater Crt.
Thornhill, Ontario
L4J 7S4 Canada

Phone Toll Free 1.866.817.5145
Phone Local 1.416.217.2727

Fax Toll Free 1.866.327.8364
Fax Local 1.416.217.0199

info@canadianpharmacychoice.com
www.canadianpharmacychoice.com

 I understand and agree that 1) all sales are final 2) the pharmacy will not accept medication returns 3) a patient profile form must be and is on file for this patient 4) I have read and am bound by Canadian Pharmacy Choice’s and the pharmacy’s terms and conditions 5) I must provide a valid prescription for this order.

Date_______DD_______MM_______YY________

Print Name______________________________

Signature_________________________________
 
 
 

Instructions

Send prescription, order and payment to:

Canadian Pharmacy Choice
33 Coldwater Crt.
Thornhill, Ontario
L4J 7S4 Canada
Phone: 1.866.817.5145 Fax: 1.866.327.8364
 
 
 
 

For Internal Use___________________________

Rep Code_______________________________

Membership Code_____________________

  ∅ Internet Order (Secure Digital Authorization)

  ∅ Phone Order (Verbal Authorization Per Above)