New Patient Mail / Fax Order Form

Fax to: 1-888-536-8192

Or mail to:

Online Pharmacies Canada
Suite #2001, 7495 132nd Street,
Surrey, BC., Canada V3W 1J8

Cover Sheet

Total Number of Pages (including this sheet)


Your Name: (as written on prescription)

1. Complete & sign the attached form

2. Fax toll-free 1-888-536-8192 (or mail) along with a copy of your original Prescription and a copy of a Picture ID or 2 of the following: birth certificate, passport, voter's card, marriage certificate, or military ID.

** Please note: if you order your prescriptions by mail, there is a $9.95 USD shipping fee ($15.95 USD for cold-pack items) per patient for an unlimited number of prescriptions. All prescriptions will be authorized for a 1-year period if indicated by the physician and will be honoured from the date on the prescription form. All prescription drug prices include prescribing fee and pharmacy dispensing fee.

Please Attach Prescription to the Box Below Before Faxing:

Attach Prescription Here


 

Cart Details
Rx-= Prescription Required      Rx-= No Prescription Required
Medication 1  Qty 
Medication 2  Qty 
Medication 3  Qty 
Medication 4  Qty 
Medication 5  Qty 
Medication 6  Qty 
Medication 7  Qty 
Medication 8  Qty 
Medication 9  Qty 
Medication 10  Qty 

Billing Address
First Name:  
Last Name:  
Address:  
 
City / Town:  
State / Providence:  
Zip / Postal Code:  
Email:  
 

Shipping Address
First Name:  
Last Name:  
Address:  
 
City / Town:  
State / Providence:  
Zip / Postal Code:  
Email:  
 

Payment Method
For added security, a customer service specialist will call to collect credit card information. We proudly accept:
    

New Patient Questionnaire

If you have previously purchased from Doctor Solve Healthcare Solutions, you do not need to fill out the patient questionnaire below.

Pet Information  
Name of Pet:  
Species:  
Breed:  
Age:  
Sex (M/F):  
Weight:  
Allergies (If Any):  
Medical Conditions:  
Owner First Name:  
Owner Last Name:  
Date Of Birth:  
Telephone:  
Street Address:  
City / Town:  
State / Province::  
Zip / Postal Code:  
   

Physician Information  
Last Name:  
First Name:  
Phone:  
Fax:  
Address:  
City / Town:  
State / Province:  
Zip / Postal Code:  
   

Terms of Agreement

agreement for services

I ____________________ of the city of ________________ in the state of ___________
have read, understood and agree to the following:
1. I, __________________ am not seeking medical advice or treatment of any kind whatsoever in coming to Online Pharmacies Canada and its veterinarians, employees, officers, agents and all others acting through or for it.
2. Neither Online Pharmacies Canada, nor any of its veterinarians, employees, officers agents and all others acting through or for it, or anyone that is acting on its behalf, is providing medical advice, professional advice, treatment advice or treatment of any kind whatsoever to me.
3. I am coming to Online Pharmacies Canada for the SOLE PURPOSE OF OBTAINING A PRESCRIPTION AT A LOWER PRICE THAN IN THE UNITED STATES OF AMERICA.

I _________________ hereby acknowledge that this prescription was originally prescribed by my American veterinarian whose name is __________________________ and that I will continue to have my pet's medical condition and medications obtained in Canada monitored by my American veterinarian in the United States of America.

I, ________________have given the authority to Online Pharmacies Canada to act as my agent and/or representative to facilitate the purchase of prescription medicine from a licensed Canadian pharmacist.

In consideration of approving this prescription and in consideration of Online Pharmacies Canada making this prescription, I agree not to sue Online Pharmacies Canada, its veterinarians, employees, officers, agents and all others acting through or for it, and release Online Pharmacies Canada, its veterinarians, employees, officers, agents and all others acting through or for it, from all legal liability for any problems associated with the prescription.

Our responsibility stops at the signing of the prescriptions.  We are not responsible for problems with the pharmacy.

I hereby agree that the relationship between and the resolution of any and all disputes arising between me and Online Pharmacies Canada, its veterinarians, employees, officers, agents and all others acting through or for it, shall be governed by and construed in accordance with the laws of the Province of British Columbia, Canada.. I hereby acknowledge that the Courts of the Province 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 out of the signing of this prescription, and I hereby agree that I submit irrevocably to the exclusive jurisdiction of the Courts of the Province of British Columbia

All of which is agreed.

Printed Name: __________________________________
Signature:_________________________________ Date: __________________
Printed Name of Witness: __________________________________
Signature of Witness __________________________Date: ___________________
Relationship of Witness: ________________________________________________



© Online Pharmacies Canada, Surrey, British Columbia, Canada