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Pioglitazone.ca
Call Toll Free 1-877-771-7792 – Fax Toll Free 1-877-771-7793
New Customer Order Form - Page 1 of 3
The “Order Form” is filled out once and kept on file. For refills or new prescriptions, just call toll free, email or fax toll free. PART 1: GENERAL CUSTOMER INFORMATION
____________________ _____________________________________________________________________________ ___________________________________________________________________________________________________ Street Address (where medication will be shipped) _____________________________________ __________________________________ _______________________ _________________________________ ____________ ___________ _______________ _____________________ Date of Birth (Month/Day/Year) Age Sex Height Weight (_____) _______________________ (_____) _________________________ (_____) _________________________ Home Phone Work Phone Fax Number (if available) ___________________________________________________________________________________________________Email Address (if available) PART 2: MEDICAL HISTORY
Please indicate any known drug allergies or adverse reactions you may have now or have experienced in the past: ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ Please list all medications you are currently using, including the dosage and frequency: Medication Dosage Frequency Diagnosis
1)____________________________ ____________ ______________ ______________________________________ 2)____________________________ ____________ ______________ ______________________________________ 3)____________________________ ____________ ______________ ______________________________________ 4)____________________________ ____________ ______________ ______________________________________ 5)____________________________ ____________ ______________ ______________________________________ _________________________________________________________ (________)_______________________________ ________________________________________________________________________ Pioglitazone.ca
Call Toll Free 1-877-771-7792 – Fax Toll Free 1-877-771-7793
New Customer Order Form - Page 2 of 3
PART 4: MEDICATION(S) BEING ORDERED
Medication Dosage Quantity
(Example) Pioglitazone 30mg 100
1)___________________________________________ ____________________ _______________________ 2)___________________________________________ ____________________ _______________________ 3)___________________________________________ ____________________ _______________________ 4)___________________________________________ ____________________ _______________________ 5)___________________________________________ ____________________ _______________________ Would you like your medications shipped in childproof containers? Yes__________ No____________ The charge to ship and insure this entire order will be $9.95. Shipping will not be charged on your first order! PART 5: PAYMENT INFORMATION
Please select your method of payment: Visa _____ MasterCard _____ American Express ______ Check/Money Order _____ All check or money orders should be made payable and mailed to: Canadian Prescription Savers (Pioglitazone.ca is owned by Canadian Prescription Savers, Ltd) Vancouver, British Columbia Canada, V5X 2S4 If paying by credit card please complete the following information: If you are not comfortable sending your credit card information in the mail or via fax (we completely understand!), leave this section blank and when we call you to confirm we’ve received your order, we’ll collect it. ____________________ _____________________________________________________________________________ Prefix (Mr, Ms, Etc.) Full Name Including Middle Initial ___________________________________________________________________________________________________ _____________________________________ __________________________________ _______________________ _____________________________________________________________________ ___________________________ (For your safety and security, Pioglitazone.ca requires that you enter your Card Verification Value (CVV) code when paying by credit card. The CVV code is a three digit number which appears on the back of Visa and MasterCard, typically in the signature line. On American Express cards, it’s a four digit number which appears on the front of the card above and to the right of the card number. Orders that do not include CVV codes will not be processed.) Pioglitazone.ca
________________________________________________________________________ Call Toll Free 1-877-771-7792 – Fax Toll Free 1-877-771-7793
New Customer Order Form - Page 3 of 3
PART 6: CUSTOMER AGREEMENT
I confirm the following information and provide the following release:
1. I hereby state that I am of the age of majority in the jurisdiction where I ordinarily reside and I am fully competent to make my own health care decisions. 2. I state that I have had a physical examination by the physician whose care I am under within the last twelve months and I understand that it is my responsibility to have regular physical examinations by the U.S. licensed physician whose care I am under including all suggested testing by said physician to ensure I have no medical problems, which would constitute a contradiction to me taking the medications being prescribed for me. 3. I will only use the medication as prescribed by a duly qualified medical practitioner.
4. I will not allow anyone else to use the ordered medication. 5. I acknowledge I may not return any medication dispensed to me. 6. I am not seeking medical advice or treatment of any kind whatsoever from Pioglitazone.ca or its affiliated pharmacy, or the Canadian licensed co-signing physician and I am dealing with Pioglitazone.ca and its affiliated pharmacy for the sole purpose of obtaining medication at a lower price than my home country. 7. I hereby acknowledge that my personal doctor originally prescribed the prescription I wish to obtain. 8. I release and discharge Pioglitazone.ca and it's affiliated pharmacy, including all of its employees and contractors including pharmacists, pharmacy technicians, physicians, nurses, and receptionists from any and all liability whatsoever associated or connected to the use of any and all of the medications prescribed to me and including but not limited to any adverse effects I may suffer from these medications. 9. I understand the risks of taking medication and I understand that all of the possible risks and/or complications that may occur may have never been recorded before. 10. By agreeing to this waiver I agree to release liability and hold harmless the issuing pharmacy, physicians, directors, officers, employees, representatives, and independent contractors from all causes of action, suits, penalties, liens, judgments, liabilities, obligations, losses, actual or consequential damages and actual or threatened claims which may arise at any time by reason of relating to, arising directly or indirectly out of any matter whatsoever related to the prescribing or dispensing of my prescription medications. 11. I acknowledge that the physicians and pharmacists working on my behalf are located and licensed to practice medicine and/or operate a pharmacy in Canada and that all treatment that I am receiving from the said physician and pharmacists is received in Canada. 12. I agree to the jurisdiction of the province in Canada in which the pharmacy resides and where the prescription was issued, where the Pharmacy provider maintains its offices, meaning that any dispute that arises between the providing Pharmacy and me will be governed by the laws of that Province in Canada where the pharmacy is located and any applicable federal laws of Canada; and 13. If any dispute does arise between Pioglitazone.ca or its affiliated pharmacy its pharmacy provider and me about rights or liabilities arising from the purchase of my medication that cannot be resolved on the basis of both sides acting reasonably, then such dispute shall be referred to arbitration in the province of Canada in which the pharmacy resides. This agreement represents the complete and entire agreement between Pioglitazone.ca and its affiliated pharmacy and me. 14. On orders where refills are prescribed, I agree to contact Pioglitazone.ca 21 days in advance of refill due date to ensure an uninterrupted supply of medication and I understand no refills will be shipped without contacting Pioglitazone.ca.
15. I understand that due to the laws of Canada, prescription medications ordered cannot be returned. If errors occur in my order due to the fault of Pioglitazone.ca my order will be replaced at the expense of Pioglitazone.ca.
I have read, understand and agree to all the terms and conditions of the Customer Agreement and authorize Pioglitazone.ca or its affiliates to charge my credit card or debit my bank account for the products I have __________________________________________________ _________________________________ Please note that it takes at least 7-10 days for you to receive your prescriptions from the time we’ve received your completed Order Form, your VALID American prescription and your method of payment. If paying by check or Money Order, please add an additional 7 days to allow for check processing times.
Please keep in mind that during the holiday season the post office gets very busy and statutory holidays can also create delays in receiving your order. We strongly recommend that you order your prescriptions 20 days in ________________________________________________________________________

Source: http://pioglitazone.ca/downloads/cps-hp.pdf

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