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All prescriptions dispensed by Access Canada Drug Mart: 906 Main St. Winnipeg, Manitoba R2W 3P3, Canada

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PATIENT PROFILE FORM

No hidden fees. All prices include physician review fees and pharmacist dispensing fees.

Those entries with an asterisk * are required fields to submit this form.

STEP 1

ORDERING INFORMATION

First Name*
Last Name *
Email *
Street Address *
City/Town*
State
Other Territory	Enter if not a state
Zip Code*
Country*

Daytime Number*	( ) Area code Phone number
Evening Number	( ) Area code Phone number
Cell Phone Number	( ) Area code Phone number
Fax Number	( ) Area code Phone number

STEP 2

ORDERING MEDICATION

Product(s)	Strength	Qnt	Price	Total
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STEP 3

PAYMENT INFORMATION

Delays in processing and shipping orders may result if payment information is incomplete, incorrect or missing. Please call toll-free 1-866-888-3784 for drug prices or an order total if your choose payments by 'U.S. Dollar Money Order' or 'By Personal Cheque'. Payment must be received IN FULL BEFORE Orders are shipped.

Payment Option*
-- If payment by Visa or Mastercard, fill in the information below. --
Cardholder's Name:
Credit Card Number:
Cardholder Billing Address: (City, State & Zip)
Expiry Date:	,



Please review your information before submitting this form!
Press the SUBMIT button only once to send your information.

Access Canada Drug Mart is a Canadian Pharmacy, operating in the province of Manitoba under license by the Manitoba Pharmaceutical Association, license #32386

Be advised that, given the international nature of the practice of International Prescription Service (IPS) pharmacy, there may be limitations in the ability of the Manitoba Pharmaceutical Association (MPhA), which is the statutory licensing authority for pharmacies and pharmacists in the Province of Manitoba, to investigate and prosecute complaints from persons who receive services or products from an IPS pharmacy.

Manitoba pharmacies are not permitted to fill US physicians' prescriptions. They can only fill prescriptions issued by a physician licensed in a province or territory of Canada. M.Ph.A takes the position that it may be contrary to professional standards for a pharmacist to fill prescriptions by a physician, licensed in a province or territory of Canada, who has not established an acceptable patient physician relationship with you.

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