CanadaEastPharmacy.com
13 East Main Street,
Port Elgin, NB
E4M 2X8
Canada
www.CanadaEastPharmacy.com
Toll-free fax: 1 866 430 5481
Toll-free phone: 1 866 430 5480

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Patient Registration Form

Please complete and sign the following three page form. Fax or mail this form along with a photo-id. Have your doctor fax the prescription to us directly and ask your doctor to include both DEA number and License number.

First Name: _______________________________________________________
Last Name: _______________________________________________________
P.O. Box or Apartment Number: _______________________________________________________
Street: _______________________________________________________
City: _______________________________________________________
State or Province: _______________________________________________________
Postal or Zip: _______________________________________________________
Country: _______________________________________________________
Date of Birth: _______________________________________________________
Gender: ___ Male ___ Female
Home Phone: _______________________________________________________
Work Phone: _______________________________________________________
E-mail: _______________________________________________________

Do you wish us to contact your physician regarding automatic 30 day delivery
and monthly charge to your credit card? Check One: ____ Yes or ____ No

In case you cannot be reached please specify below a contact person, telephone number, and their relationship to you.

Contact First Name: ______________________ Last Name: ________________________

Telephone: __________________________ Relationship: __________________________



Your Doctor's Information

Physician's First Name: _______________________________________________________
Physician's Last Name: _______________________________________________________
P.O. Box or Apartment Number: _______________________________________________________
Street: _______________________________________________________
City: _______________________________________________________
State or Province: _______________________________________________________
Postal or Zip: _______________________________________________________
Telephone: _______________________________________________________
License Number: _______________________________________________________
DEA Number: _______________________________________________________
Fax: _______________________________________________________

Patient Profile

Please provide the following information if applicable.
Other Medications:
______________________________________________________________

______________________________________________________________

______________________________________________________________

______________________________________________________________

Allergies:
______________________________________________________________

______________________________________________________________

______________________________________________________________

______________________________________________________________

Medical Conditions:
______________________________________________________________

______________________________________________________________

______________________________________________________________

______________________________________________________________



Payment Method

We accept either Visa or Mastercard. Your card will be billed when your medication is mailed out and Canada Post has a record of the shipment.

Check One: _____ Visa or _____ MasterCard

Cardholder's Name: _____________________________

Credit Card Number: _____________________________

Expiration Date(mm/yy): __________________________

Cardholder's Signature: ___________________________

Billing Address (if different from patient's home address):

Address: _____________________________________________

State and Zip Code: ____________________________________

Patient Agreement and Authorization

      I hereby appoint CanadaEastPharmacy.com as my agent for obtaining a prescription from a Medical Doctor in Canada which corresponds to the prescription included in this order.
     I am of legal age and make this decision according to the laws of my place of residence. This prescription is for my use only, as prescribed by my own physician, under his/her medical advice and consultation only.
     I am not relying on any medical advice from CanadaEastPharmacy.com but take this prescription under the advisement of my own qualified physician.
     In the event of an adverse reaction to a prescription I will immediately contact the physician who provided this prescription. I am aware that CandaEastPharmacy.com has issued no warranties or made no representations to me with respect to the delivered medication.
     I hereby release and save CanadaEastPharmacy.com and its employees and contractors (including physicians, pharmacists, and pharmacy technicians) harmless from all suits, demands, liabilities, losses and damages of any kind arising from my use of the medication received from CandaEastPharmacy.com due to my breach of any terms of the conditions in this agreement.
     Nothing in this release shall be deemed to release CanadaEastPharmacy.com from compliance with the applicable standards of practice or usual professional duties and obligations which a pharmacist owes.
     I have read, understood, and agree to the terms of this waiver which will be governed by and construed in accordance with the laws of the province of New Brunswick, Canada.

Patient's Name: __________________________________

Patient's Signature: ________________________________ Date: ________________