Generic Pharmacy c/o CanTrustRx Inc. | #7 - 2 Donald Street, Winnipeg, MB, Canada R3L 0K5| Phone 1:800-640-2221 | Fax: 1-800-640-5553
Generic Pharmacy is an division of CanTrustRX Limited
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Form 1- MY PERSONAL INFORMATION |
First Name: ______________________ Last Name: ______________________________
Address: ________________________________________________________________
City: ___________________________ State: ______________
Zip Code: ________________
Phone: ________________________ Fax: ______________________
Sex: ____________________ Date of Birth: ___________________ (mm/dd/yy)
Weight (lbs): ________________________
Secondary Contact: _______________________________________________________
Phone: _______________________ Relationship: ____________________________
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MY PRIMARY PHYSICIAN |
Doctor’s Name: _____________________________ Phone: _______________________
Address: ___________________________________
City/Town: _________________________ State: _______________________
Zip Code: ______________
Fax: _________________________
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MY CURRENT MEDICATIONS |
These are the medications that have been prescribed to me to treat the following conditions:
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How long |
Condition (if known) |
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Please answer the following questions by circling Yes or No:
We do not usually ship medications in Child Proof Containers. If you require Child Proof Containers, please indicate by circling YES
It is mandatory to have had a physical examination in the last 12 months.
Have you had one? Please circle Yes or No
Will you accept a
generic version of the drug ordered to save more money?
Please circle Yes or No
Patient Signature: ______________________________________
Print Patient Name: _____________________________________