Order Forms

Spouse or otherperson's name if you want packages shipped together_______________________

Have they previously filled out a Questionaire?___________

Primary Physician's Name_________________________

Address____________________________________________________

Phone(____)_____________________ Fax(____)_______________________

Please note: it is mandatory to have had a physcian's examination in the last 12 months. Have you had one?________________

Please list all medications you are currently using, including the dosage and frequency.

Please list all known allergies___________________________________________________________

Patient medical history
Do you have a history or early finding suggestive of the following? (Please check all that apply)

What type, frequency and duration of exercise..______________________________________ ________________________________________________________________________________________________
If you checked any of the above questions, please elaborate below. (ie., duration of illness, any treatment or surgery recieved, amount smoked and for how long?)__________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________

Medication being ordered	Dosage or strength	Quantity	Generic substitution	Price in US dollars

*We are required to dispense pills in child resistant containers unless indicated*

Cardholder(name on card)______________________ Cardholder address________________________
Credit card number___________________________ Cardholder city___________________________
Credit card expiry_____________________________Cardholder state___________________________
Cardholder zip code_______________________

*Money orders are the preferred method of payment.Personal cheques are accepted but must clear before processing will begin. This may add up to 7 days to the shipment times. ( No third party cheques accepted.)

*Note in order to order from Glenway Pharmacy you must have been on the medication for a minimum of 30 days.

Informed consent for Patient Counseling:
We provide patient counseling from a licensed pharmacist on all prescriptions.
This includes:
1.Medication identification (name, dose and use)
2.Directions for use and what to do if you miss a dose
3.Drug or food interactions and common side effects
4.Special storage requirements and refill information
When would you like a pharmacist to call you to discuss your medication? ________________

Signature:______________________________ Date:_______________________

No prescriptions will be filled without a signed and dated copy of this form

1. The Patient is of the age of majority in the jurisdiction, in which the Patient resides and is fully competent to make their own
health care decisions.

2. The Patient confirms that the pharmaceutical(s) ordered by the Patient ("the Ordered Product") were prescribed by a duly
qualified medical practitioner in the place of residence of the Patient. The Patient has not violated any laws in obtaining the
prescription and that the Ordered Product will not be used by no other person and in no manner except as prescribed by the
original prescribing physician ("The Patient's Physician").

3. The Patient agrees to direct all questions to The Patient’s Physician. The Patient will consult The Patient’s
Physician before taking any new drug, natural product, or changing their daily health regiment.

4. Glenway Pharmacy requires the patient to submit a new medical questionnaire every time there is a change to their
medical status. The Patient understands that it is their responsibility to have The Patient’s Physician conduct regular
physical examinations (minimum every 12 months), including any and all suggested testing by The Patient’s Physician
to ensure that they have no medical problems which would constitute a contradiction to them taking medications
prescribed for them. The Patient agrees that should they suffer any adverse affects while taking any prescription
medication that they will immediately contact The Patient’s Physician and that in the event they come under the care of
another physician, the Patient will inform this physician of any and all medications that have been prescribed.

5. The Patient must take responsibility to secure their own medication stock from a local pharmacy in the interim if such
an event was to evolve, ensuring that at no point they are without medication.

6. The Patient grants Limited Power of Attorney to Glenway Pharmacy, for the limited purpose of signing any
documents as required by the laws of the Province of Manitoba (Canada), which are necessary to permit the
delivery of the Ordered Product to the Patient, in the same manner as the Patient could, if the Patient had personally
attended the pharmacy in Winnipeg, Manitoba, Canada.

7. The Patient agrees that any dispute that arises between Him or Her and Glenway Pharmacy shall be heard by the
courts of Manitoba, Canada. The courts of Manitoba, Canada shall have the sole and exclusive jurisdiction, and that
the laws in force in Manitoba, Canada, shall apply to any and all disputes that may arise.

8. The Patient must honestly report all requested information and immediately update any
changes to his or her record.

9. The Patient understands that the Ordered Product may not be exchanged or returned for a refund once
purchased and shipped.
BY SIGNING THIS DOCUMENT THE PATIENT CONFIRMS THAT HE OR SHE HAS READ AND UNDERSTOOD EACH OF
THE ABOVE TERMS AND HAS AGREED TO EACH ONE.

Name: __________________________ Date: ___________ Signature: __________________________________

Medication Name	Strength/dosage	Direction for use