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 3 PRESCRIPTION REQUEST FORM |
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Medication
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Dose
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Quantity
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Price
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Shipping
and Handling: There will be a $15.00 shipping fee per household
ordered at the same time |
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TOTAL
(all amounts are in US dollars)
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MY BILLING INFORMATION |
Please input the EXACT credit card billing information, or your order will be delayed.
Type of card: Visa ____ MasterCard ____ American Express _____
Cardholder’s Name: _____________________________________________________
Credit Card Number: _____________________________________________________
Credit Card Expiration Date: _______________________________________________
Address to send receipt to: ________________________________________________
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As a member of the Manitoba Pharmaceutical Association, we pledge to keep all of our clients well informed about the prescription medications we provide. We also ensure that these consultations will be conducted in an atmosphere of confidentiality and privacy. These consultations are designed to provide you, our clients, with important information regarding your prescription medications.
This information includes:
- The drug name
- What the drug does
- What to do if a dose missed
- Common side effects
- The importance of taking the drug
- How and at what time drug as directed, regularly or the drug should be taken
- when needed
- Refill information
- Food, drink, other drugs or activities to avoid
- Special storage requirements
A reminder to please consult your doctor or pharmacist before taking any medications not prescribed by your doctor.
To confirm that you have read the above please sign and date below:
Patient Name: ____________________________ Date: ______________________
Would you like our
pharmacist to contact you to discuss any of these issues?
Please Circle: YES or NO
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