Personal Information

    * Required Fields

    • Gender
      Male Female
    • Would you like to receive a call to remind you of future refills ?
    • It is mandatory that you have had a complete physical exam in the last 12 months. Has this been done?
    • Your medication will be packaged in child proof containers unless your decline. Do you decline child proof containers ?

    First Time Patients

    Please fill out this section if you are a first time patient, or would like to update your information with us.

    • Do you have any drug allergies ?
    • Medication Dosage Frequency

    Medication

    For medication(s) that you wish to order,please enter the quantity, and listed price, as obtained through our website or customer service center.An original prescription from your doctor’s office is required (mailed,faxed or emailed) PRICING IN $US DOLLARS
    • Generic Ok? Medication strength qty price
      SHIPPING:
      check box if you NOT want childproof caps.TOTAL:
    • Patient Agreement
      I acknowledge and agree with Access RxBudget Mart pharmacy as follows:
      1). I am 18 years old or older in the jurisdiction that I reside.
      2). I have fully and accurately disclosed my personal and medical information and
      consent to its use by the pharmacy and its employees and agents.
      3). I authorize the pharmacy 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 the pharmacy; and (b) packaging my prescriptions and having
      them delivered to me.
      4).Title to my medications passes from the pharmacy to me when they have left the pharmacy location.All agreements reached or contracts formed with the pharmacy shall be deemed to be made in the Province of Manitoba, Canada and the laws of the Province of Manitoba shall have sole and exclusive jurisdiction over any dispute arising between myself and the pharmacy, it’s affiliates, parent company, related companies,subsidiaries, officers, directors and employees.
      5).This agreement shall apply to every sale by the pharmacy to me and may not be altered unless in writing and signed by both the pharmacy and me.
      6). I acknowledge that due to the nature of the products ordered, all sales are final and I cannot return products for refund or exchange.By signing this agreement, I confirm I have read and understood these terms and that my information is true and correct. Furthermore, I agree that the terms herein
      are binding on me and my heirs, assigns, successors and personal representatives.
      CALL TOLL-FREE: 1-877-242-9090
      FAX TOLL-FREE: 1-877-242-9090
      By signing this document, I confirm I have read and understood these terms
      and that my information is true and correct. Furthermore, I agree that the
      terms herein are binding on me and my heirs, assigns, successors and
      personal representatives.

    • Affiliate Box

    • Note: payments by money order or check must be mailed to us BEFORE any medications are shipped.