Meds for Less Pharmacy

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Your Personal Contact Information

First Name *		Middle		Last Name *

Street Address *

City *		State *		Zip Code *

Home Phone *		Work Phone		E-mail Address For order confirmation/updates only.

Method of Payment

Choose One *
Please note: for security purposes, we request you call in your card number and expiration date once you have finished this form.

Your Personal (Or Pet Information If Ordering for Pet)

Birth Date *		Height *		Weight *

Sex *

Male

Female

Smoking? *

Yes

Kidney Disease? *

Yes

Liver Disease? *

Yes

List all illnesses or medical conditions you have below: *

List all drug allergies: *

List all current medications (including over-the-counter and herbal): *

By selecting "I Agree" below, I confirm all information to be true and accurate to the best of my knowledge and I consent to my doctor(s) being contacted if additional medical information is required. *

Your Order

Physical Exam
Have you had a physical examination by a qualified Medical doctor in the last 12 months? (This is mandatory in order to have a Canadian physician countersign your prescription.)

Check Price

Medication Name		Strength		Qty		Price

Medication Name		Strength		Qty		Price

Medication Name		Strength		Qty		Price

Medication Name		Strength		Qty		Price

Medication Name		Strength		Qty		Price

Medication Name		Strength		Qty		Price

Medication Name		Strength		Qty		Price

Medication Name		Strength		Qty		Price

Medication Name		Strength		Qty		Price

Medication Name		Strength		Qty		Price

Have you had this medication(s) before? *

Substitute generic when possible? *

Doctor's Name *

Office Phone *

By selecting "I Agree" below I confirm that I have read and agree to the Patient Disclaimer/Release. *

Read Disclaimer/Release

Please list any additional comments below.

* Required to submit this form

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