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FOR THE NEW CUSTOMER:

Thank you for your interest in our prescription service. In order to fill your prescription, we will require certain information from you, which includes:

  1. Signed Patient Agreement
  2. Patient Medical Information and Order Forms
  3. Your Prescription
  4. Photo Identification (Driver’s License, Passport)

Note: If you do not have a copy of your prescription, we will need your physician’s name, phone and fax number so that we may contact him to receive a copy of the prescription.

Allow 2-3 weeks after receipt of order for delivery.

Place Order:

Step 1. Complete and Sign the:

  1. Patient Medical Information Form
  2. Patient Agreement
  3. Order Form
  4. Credit Authorization Form

Step 2. Send us your order.
There are 2 ways to send in your order:

  1. Print and mail the signed forms and the original prescription and photocopy of photo identification.
  2. Fax the signed forms to our fax number:

Step 3. After you have sent your information to our office, call 604-687-2564 to ensure we have received your paperwork.

T 604-687-2564
F 604-685-9721

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

To enquire about the cost of your medication, email altermed@portal.ca

All charges included in quoted price of prescription.

 

 


PATIENT MEDICAL INFORMATION FORM (Please Print)

Your Personal Information
Please provide the following contact information:
Name: _________________________________

Street Address: ______________________________________________________________

City: ____________ State/Province_________ Zip Code: ________

Country: ___________

Work Phone: ____________ Home Phone: ______________ Best Time to Call _________

E-mail: _________________________

Date of Birth: _______________ Sex: ________ Height: __________ Weight: _________

You MUST answer ALL of the following QUESTIONS for your order to be FILLED.
Have you had a Physical examination by a qualified Medical Doctor in the Last 12 Months?
Yes ______ No _______

If not we cannot fill your prescription.

Your Family Physician Information:
(Please provide information for your Primary Physician)

Name: ______________________________________

Street Address: ______________________________________________________________

City: ___________ State/Province: __________ Zip Code: ________ Country: _________

Work Phone: _________________________ Home Phone: __________________________

Personal Medical Information

Do you have a history of or any early findings suggestive of the following:

  Yes No
1. Blood Disorders ___ ___
2. Cancer ___ ___
3. Immune disorders ___ ___
4. Poor wound healing ___ ___
5. Neurological disorders ___ ___
6. Diabetes, thyroid or other endocrine disorders ___ ___
7. Known nutrition deficiency including disorder minerals or electrolytes ___ ___
8. Lipid or cholesterol ___ ___
9. Heart disease including atherosclerosis, angina, heart failure or history of heart attack ___ ___
10. Renal or kidney disease ___ ___
11. Liver disease ___ ___
12. Orthopedic or muscle disorder, including fracture, joint disorder or carpal tunnel ___ ___
13. Emotional disorders ___ ___
14. Surgery ___ ___
15. Glaucoma ___ ___
16. Hyperlipidemia (high cholesterol) ___ ___
17. Chemical dependency ___ ___
18. Upper respiratory disorders ___ ___
19. Smoker ___ ___
20. Lung disorder (i.e., asthma,emphysema) ___ ___
21. Rheumatoid arthritis,lupus, or connective tissue disease ___ ___
22. High blood pressure ___ ___

 


Please tell us about any illness or medical condition you may have or not listed above:

______________________________________________________________

______________________________________________________________

______________________________________________________________

Please list all allergies and/or sensitivities?

______________________________________________________________

______________________________________________________________

______________________________________________________________

 

 

Please list all current medications.
(Include Over The Counter Medication and Herbal Medications)

Name Strength Directions
______________ ______________ ______________
______________ ______________ ______________
______________ ______________ ______________
______________ ______________ ______________
______________ ______________ ______________
______________ ______________ ______________
______________ ______________ ______________
______________ ______________ ______________
______________ ______________ ______________

Please indicate here if you will accept the generic version of the medication that you are requesting.

Yes __________ No ___________


We do not ship prescriptions in childproof containers. Do you require childproof containers?

Yes ___________ No ____________


Prescription Details

Drug name/Brand Amount Dosage

I hereby confirm that all information provided is true and correct to the best of my knowledge and I consent that my Doctor can be contacted if additional medical information is required.

Signed: ________________________________

Date: _________________________

RETURN BY MAIL TO:
Canada Global Drugs
5413 West Boulevard
Vancouver, B.C.
Canada V6M 3W5.

PLEASE ATTACH YOUR PRESCRIPTION HERE

 

PLEASE ATTACH PHOTO IDENTIFICATION HERE

 

CUSTOMER AGREEMENT FORM

I,_____________________, of the City of _________________ in the state of _______________ in the Country of _______________have read, understand and agree to the following:

AUTHORIZATION AND CONSENT
I hereby acknowledge and understand that CanadaGlobalDrugs.com is not a pharmacy in any form and does not practice pharmacy or medicine. I understand that in placing this order I become a customer of Kripps Pharmacy Ltd. I understand that my transaction in this purchase will take place with Kripps Pharmacy Ltd. and that all personal, prescription, medical, and payment information I provide in ordering my prescription medications is submitted directly to Kripps Pharmacy Ltd. With full consent to the statements above, I hereby appoint Kripps Pharmacy Ltd. and its delegates or contractors as my agents for the purposes of obtaining a prescription from a Medical Doctor in Canada which corresponds to the prescription included in this order which may include directly contacting my prescribing physician, and purchasing and arranging delivery of the medications prescribed in the Canadian prescription substantially on the terms set forth below, all to the same extent as if I personally took such steps.
I hereby consent to Kripps Pharmacy Ltd./CanadaGlobalDrugs.com and the Canadian physician supplying my order, collecting my personal and medical information, maintaining the necessary information to quickly process future orders which may include retaining on file my name, address, phone number, payment and other information.

DISCLOSURE AND REPRESENTATIONS

I represent that all of the following statements are true and agree that Kripps Pharmacy Ltd. including its contractors or agents and all others acting through or for it are relying on these representations:

  1. I am of the age of 21 years or older. I can make my own medical decisions according to the law of the place I reside;
  2. The prescription I am requesting Kripps Pharmacy Ltd. to fill for me was prescribed by a qualified physician licensed where I reside.
  3. The prescription I am requesting Kripps Pharmacy to fill for me has not been altered nor has it been filled prior to submission to Kripps Pharmacy Ltd.
  4. I have been on this prescription for over 30 days. I will use any medication dispensed for me by Kripps Pharmacy Ltd. strictly according to the instructions provided by the physician who originally prescribed the medication and I will continue to have my medical condition and medications monitored by my original physician.
  5. I am placing this order for medication for my sole use and I will not provide any quantity of this medication to any other person;
  6. I have consulted a qualified licensed physician with the prescription within the last month. I certify that I have had a physical examination by my own physician in the last 12 months;
  7. I will immediately contact my own physician who provided my prescription or treatment included with this order in the event I suffer any unexpected side effects from medication dispensed for me by Kripps Pharmacy Ltd.
  8. I am coming to Kripps Pharmacy Ltd. for the sole purpose of obtaining a prescription at a lower price than in my country of residence. I understand that no one on behalf of Kripps Pharmacy Ltd. will take any steps whatsoever to determine whether the prescription is appropriate.
  9. Neither Kripps Pharmacy Ltd. nor CanadaGlobalDrugs.com has made any representations or warranties to me, including, without limitation representation warranties with respect to any delivered medications’ usefulness or fitness for a particular purpose (including, without limitation, its appropriateness helping relieve any particular ailment, illness or disease, or its potential or actual side or adverse effects whether previously known or unknown)
  10. I am not seeking nor have received any medical advice or treatment of any kind whatsoever in coming to Kripps Pharmacy Ltd. and its employees, officers, agents and all others acting through or for it. Neither the pharmacy, nor any of its employees, officers agents and all anyone that is acting on its behalf, is providing medical advise, professional advice, treatment advice or treatment of any kind whatsoever to me.
  11. I hereby give permission to My Own Physician to release any and all medical information and data whatsoever which the Canadian physician shall request for the purpose of performing a medical review.
  12. I understand that any information provided to CanadaGlobalDrugs.com/Kripps Pharmacy Ltd. may be seen by its employees, agents and contractors and that this information will constitute a medical record.
  13. I hereby waive any requirement of the Canadian Physician to conduct a physical examination. I understand and agree that the review of my medical information by a Canadian Physician is in no way intended as a means to diagnose any medical condition and does not substitute the requirement for me to obtain my own professional medical advice from My Own Physician. I agree to a direct all questions to My Own Physician. I will consult My Own Physician before taking any new drug or changing my daily health regiment.

PURCHASE AND SALE TERMS

Kripps Pharmacy Ltd. will charge my credit card the following amounts: the medication price (in U.S. dollars). All charges are included in the price of the medication.

In the event my payment is not authorized, Kripps Pharmacy Ltd. has the right to cancel my order and attempt to provide me with notice of such cancellation. CanadaGlobalDrugs.com/Kripps Pharmacy Ltd. reserves the right to refuse to process any order in their sole discretion. Wherever possible Kripps Pharmacy Ltd. will substitute prescription drugs with lower cost generic drugs in non-child protective packaging. Kripps Pharmacy Ltd. will not exchange medication or return any monies paid once an order is filled.

RELEASE AND WAIVER

In consideration of approving this prescription and in consideration of Kripps Pharmacy Ltd. making this prescription, I agree not to sue CanadaGlobalDrugs.com/Kripps Pharmacy Ltd., its employees, officers, agents and all others acting through or for it, from all legal liability for any problems associated with the prescription.

I hereby release and save CanadaGlobalDrugs.com/Kripps Pharmacy Ltd. including their employees and contractors and all others acting through or for it harmless from any and all suits, demands, liabilities, claims, actions, expenses, losses and damages of any kind whatsoever, including, without limitation, general, direct, special, indirect and consequential damages and costs of litigation including reasonable attorneys’ fees arising from;

  1. My use of the medication dispensed for me by Kripps Pharmacy Ltd. including, without limitation, any and all side effects whether previously known or unknown.
  2. Kripps Pharmacy Ltd. or its contractors’ manner of completing any actions I have authorized above, including, without limitation, their timeliness in providing the appropriate strength, dosage, or dispensing generic drugs and non-child-protective packaging; and
  3. My breach of any terms, conditions or representations or warranties in this agreement.

Nothing in this release shall be deemed to release Kripps Pharmacy Ltd. including its employees from compliance with the applicable pharmacy standards of practice under the Pharmacy Act of British Columbia.

I hereby agree that the relationship between and the resolution of any and all disputes arising between me and CanadaGlobalDrugs.com and Kripps Pharmacy Ltd., employees, officers, agents and all others acting through or for it, be governed by and construed in accordance with the laws of the Province of British Columbia, Canada.

I hereby acknowledge that the Courts of British Columbia shall have jurisdiction to entertain any complaints, demands, claims or cause of action, whether based on alleged breach of contract or alleged negligence arising from this prescription, and I hereby agree that I submit irrevocably to the exclusive jurisdiction of the Courts in the Province of British Columbia.

All of which is agreed.

Printed Name of Patient: ______________________________________________________

Address: ___________________________________________________________________

Signature of Patient: ________________________ Date: ___________________________

Printed Name of Witness: ______________________________________________________

Signature of Witness: _______________________ Date: ____________________________
(Non-Relative)

Address of Witness: __________________________________

ORDER FORM

Your Family Physician Information: (Please provide information for your Primary Physician)

Name _______________________________________________
Street Address ________________________________________
________________________________________
City ________________ State/Province __________ Country _______ Zip Code ________
Work Phone ____________________ Home Phone _____________________

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

Your Order

 

NOTE: ORIGINAL PRESCRIPTION AND PHOTOCOPY OF PHOTO IDENTIFICATION MUST BE SUBMITTED WITH THE ORDER (Faxed or Mail)

Medication
Ordered Dosage Quantity


Payment: _____ Visa _____ MasterCard

Name on Card _______________________

Mailing Address ________________________________________________
Credit Card # __________________________________________________
Expiry Date ____________________________________________________
Signature ______________________________________________________
Date__________________________________________________________
Have you had this medication before _____ YES _____ NO

I hereby authorize Kripps Pharmacy to apply applicable charges to my credit card for the cost of prescription drugs as noted above including refills on prescriptions submitted within 3 months.

Name _______________________________

Signature ____________________________

I fully understand that the prices quoted include all fees. Kripps Pharmacy shall be entitled to substitute a prescription drug with a generic drug unless otherwise stated and Kripps Pharmacy will not use child protective packaging unless requested.

Printed Name of Patient

______________________________________________________
Last Name First Name

Address __________________________________________________________________

Phone #_____________________________

Email ________________________________

Please allow approximately 2-3 weeks for delivery. Order one contingent upon 3 month supply.

 

MAIL:

Canada Global Drugs.com
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