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ORDER FORM FOR EXISTING CUSTOMER
WITH A NEW PRESCRIPTION

Patient’s Name (print) __________________ Phone # _________________
Mailing Address ______________________
______________________ Email ___________________
______________________
Patient’s Signature ____________________
Family Physician Name _________________ Phone # __________________

It is mandatory that you have had a complete physical examination in the past 12 months. Have you had one? ____ YES ____ NO

Payment:
Any changes to your credit card information? ____ YES ____ NO
If yes, new information:

____ Visa _____ MasterCard
Name on Card________________________ Address ___________________
Credit Card # _________________________ Expiry Date ________________
Signature ____________________________ Date ______________________

Any changes in your health profile? ____ YES ____ NO
If yes, please specify.

Any changes in your mailing address? ____ YES ____ NO
If yes, please indicate.

NOTE: You must fax or mail us your new prescription with photocopy of photo identification along with this order form.

T 604-687-2564
Toll Free: 1-877-312-8822
F 604-685-9721

Email: altermed@portal.ca
Address: CANADA GLOBAL DRUGS
5413 West Boulevard
Vancouver, B.C.
Canada V6M 3W5.

PRIVACY STATEMENT
All information you provide is confidential. Information on this site is solely for educational and reference purposes. It is not intended as a substitute for diagnosis or treatment with a qualified health professional.

LIABILITY DISCLAIMER