SeniorMedications.com (Rx1.biz Pharmacy Inc.) Patient Order From
Personal Information
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Full Name                                                 Date of Birth (mm/dd/yy)
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Shipping Address
__________________ _______ _______
City                                               State              Zip
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Phone (Home)                         Phone (Work)
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Email Address
 
Patient Counseling
Manitoba law requires that we contact you to offer patient counseling. When would be a convenient time for our pharmacy to contact you?
Anytime during the day at home
Anytime during the day at work
Do not contact me as I do not wish patient counseling
Other. Please specify:
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Medications Being Ordered
Brand
Only
Generic
OK
Medication Strength Quantity Price
       
       
       
       
       
   Yes, I would like my prescription filled in Child Resistant Closures Shipping  $14.00 
   Yes, I read and understand that the nearest whole bottle will be filled when required Total   
Payment Method
VISA Mastercard
Certified Check* Money Order*
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Cardholder's Name
_____ _____ _____ _____
Credit Card Number
_____/_____  ___________
Expiry Date              3 Digit Security Code
______________________
Cardholder's Signature
OR Personal Checking Account
(Check or EFT) USA/Canada Only
Use my check information on file
I will send VOID check by:
       Fax  Email  Mail
* Make payable to Rx1.biz Pharmacy Inc.
Mailing Address: 123 St. Anne's Road
Winnipeg, MB, Canada R2M 2Z1
Toll Free Phone: 1-866-791-7711
Toll Free 24 Hour Fax: 1-866-791-9911
Website: www.SeniorMedications.com
 
Patient Disclaimer (Please Check One)
I am over the age of majority, and hereby represent to SeniorMedications.com and Rx1.biz Pharmacy Inc., its related companies, agents and employees (“Rx1.biz”) that:
1. I have fully and accurately disclosed my personal information and personal health information and consent to its use by Rx1.biz. I have had a physical examination by a physician within the last 12 months, and do not require a physical examination.
2. I authorize and appoint Rx1.biz, as my attorney and agent, to take all steps,sign all documents and to act on my behalf as if I were personally present and acting myself for the limited purposes of (a) obtaining a Canadian prescription for any prescription which I have sent Rx1.biz; and (b) packaging my prescriptions and delivering them to me. This authorization shall include, but not be limited to: collecting my personal and personal health information and disclosing such information to Rx1.biz and the Canadian physician being retained on my behalf, as required. The authorizations and consents that I am providing herein commence on the date I have signed this agreement and shall continue until I revoke them by notice in writing delivered to Rx1.biz. I understand that I can revoke the authorizations and consents I have granted herein at any time. To enhance the efficiency and timeliness of processing my order, I consent to the transmittal of my personal health information by electronic means (for example fax, internet) to Rx1.biz, the Pharmacy’s employees, agents, affiliates and service providers including any Local Physician.
3. I understand that Rx1.biz is a Canadian pharmacy licensed to practice and practicing pharmacy in the province of Manitoba and that I am purchasing medications that have been approved for sale in Canada by Health Canada. Title to my medications passes from Rx1.biz to me when my medications leave Rx1.biz�s Canadian pharmacy. All agreements reached or contracts formed with Rx1.biz shall be deemed to be made in Manitoba, and the laws of the Province of Manitoba shall have sole and exclusive jurisdiction over any dispute arising between myself and Rx1.biz, its affiliates, officers and directors.
I HAVE READ AND UNDERSTAND THESE TERMS AND AGREE THAT THEY SHALL BE BINDING UPON ME AND MY ASSIGNS, HEIRS AND PERSONAL REPRESENTATIVES.
    OR
I am the parent/legal guardian/power of attorney for the patient disclosed herein, am over the age of majority, have full authority to sign this Patient Form and have full authority to provide the above representations to Rx1.biz on the Patient's behalf.
________________________   _________________
Patient Signature                                               Date Signed

First Time Patients - Please fill out this form if you are a first time patient or use it to update your information with us.
SeniorMedications.com (Rx1.biz Pharmacy Inc.) Patient Information From
Personal Information
______________________ ___________
Full Name                                                 Date of Birth (mm/dd/yy)
_________________________________
Address
__________________ _______ _______
City                                               State              Zip
________________ ________________
Phone (Home)                         Phone (Work)
________________ ________________
Email Address                          Fax
_______  _______      ____     ____     
Height            Weight                  Male            Female
 
Doctor Information
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Primary Physician Name
_________________________________
Address
__________________ _______ _______
City                                               State              Zip
________________ ________________
Phone                                       Fax
_________________________________
Other Physician Information e.g. Specialist
_________________________________
 
Current Medications
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List current medications you are taking:
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Drugs Allergies
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List drugs you are allergic to:
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Family History (Check Applicable)
Diabetes   Breast Cancer
Prostate Cancer   Other Forms of Cancer
High Blood Pressure   Heart Disease
High Cholesterol   Migraines
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Provide more information or list other family illnesses
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How Did You Hear About Us
Where did you learn about our service?
Web             Doctor
Newspaper   Other. Please Specify:
Friend
Family                ___________________________
 
Patient Medical History (Check Applicable)
Exercise Regularly   Smoker
Alchoholism   Blood Disorders
Cancer   Immune Disorders
Poor Wound Healing   Edema
Neurological Disorders   Diabetes
Nutritional Deficiency   High Cholesterol
Upper Respiratory Disorder   Lung Disorders
High Blood Pressure   Heart Disease
Kidney Disease   Liver Disease
Orthopedic or Muscle Disorder   Emotional Disorder
Glaucoma   Chemical Dependency
Arthritis   Lupus
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Provide more information or list other personal illnesses
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Referred By: If you were referred to us by a friend or family member, please let them know about them. Used for our Referral Rewards Program
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Full Name
_________________________________
Phone Number
Your Signature
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Patient Signature                                        Date