Canadian Medication Order Form

 RBF

(Original Prescriptions must accompany this form - faxed or mailed in)

Patient Information:
Name of Patient: _________________________ Phone number: (      ) __________
Mailing Address:_____________________ Apt/Space:_______ Date: ___________
City: _____________________________ State: __________ Zip Code __________

Requested Medication

Dosage
(mg.)

Quantity

Price
       
       
       
       
       
       
       
       

Total Enclosed $ _______________

I hereby waive my right to pharmacy counseling, as I have been previously counseled regarding the above medications.  (Optional)
Please do not contact me regarding this order, but rather ship the medication as described above.   (Optional)

Payment Method -      ____Mastercard    ____Visa 
                                     ____Money Order ____Certified Check
Name on Card: __________________________________________________ 
Credit Card # __________________________________________ Exp:______
Signature: _________________________________     Date:_______________
How to order:
1. Mail or fax this form along with the release form, patient allergy form AND prescriptions (with as many refills as
    you might need later).
2. We verify the prescription with our team of physicians.
3. We contact you for payment if necessary (please ensure that your name and phone number are on the prescription).
4. The prescription will be sent to your home.  .  New prescriptions generally take up to
    4 weeks for delivery.  Refills generally take 2 to 3 weeks for delivery.
Our toll-free fax number is 1-866-773-2696.
If you have any questions, please call us at 1-888-773-2698.
Mediplan Pharmacy
P.O. Box 84
Minnedosa, Manitoba, Canada  R0J 1E0