Canada Medicose Discount Prescription Drugs - Online Canadian Pharmacy

You are an existing patient of Canada MEdicose and would like to order
prescription medicines.


First Name:	*
Last Name:	*
E-mail Address:	*
Telephone Number:	*
Has your address changed:	Yes No
If yes, please enter your current address:
Please list the name, quantity, dosage and strength of the medication you are requesting.*


Has your medication or health changed from the last time you purchased medicines from Canada Medicose? Yes No
If yes, please describe in the box below:

Please choose 1 of the 3 methods below.
1. I will Fax my prescription(s) to Canada Medicose.

2. I permit Canada Medicose to get a fax copy of my prescription(s) from my local Family Physician. (If you choose this option, please provide the following information):

Physician's Name:
Address:
Telephone Number:
Fax Number:

3. I have remaining refills at my local pharmacy and allow Canada Medicose to contact my local pharmacy and transfer my refills to Canada Medicose. (If you choose this option, please provide the following information):

Name of Drug Store:
Prescription Number ( Rx number ):
Telephone Number:
Fax Number:

Press the "Submit Button" only once, to send your information. Please type your full name to authorize this submission. *