Rx Budget

Personal Information

* Required Fields

Full Name

Gender
Male Female
Street Address
Country

State

City

Zip Code
Phone(home)

Phone(other)
Email Address

Birth Date
Best time to be contacted by our Pharmacist
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.

Full Name of Secondary Contact
Relationship to You

Phone Number
Primary Physician's name
Clinic Name
Street Address
City

State

Country

Zip Code
Phone Number

Ext

Fax Number
Do you have any drug allergies ?
If yes Please specify

Current medication, OTC, Herbal Products (list only the medications that you are not ordering)

Medication	Dosage	Frequency

Full Name of Person who referred you

Phone Number

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 RxBudget 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: 1-844-252-4040
FAX TOLL-FREE: 1-844-252-4040
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.
Patient Signature

Date

Affiliate Box

Enter Affiliate Code, If applicable

Card Type
Cardholder's Name
Cardholder's Address
City

State

Country

Zip Code

Card Number

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

Personal Information

First Time Patients

Medication

Affiliate Box