Classic DrugStore Order Form

ClassicDrugStore
Phone 1-800-707-9980 Fax 1-800-707-9980 Order Form
Instructions:- 1. Please fill this form. 2. Provide your Contact Information & Order Information. 3. Provide your Credit Card Information. 4. After filling this form take printout & fax or mail us.


1. Full Name
2. Address
3. State
4. City
5. Postal Code
6. Phone
7. Country
8. Date of Birth
9. Height
10. Weight
11. Sex	Male Female

12. Have they previously filled out a Questionnaire?		Yes No
13. Spouse or other person’s name if you want packages shipped together
14. Primary Physician's Name
15. Physician's Address
16. Physician's Phone
17. Physician's Fax

Please note: it is mandatory to have had a physician’s examination in the last 12 months. Have you had one?

● Please list all medications you are currently using, including the dosage and frequency.
Medication Name	Strength/Dose	Directions for use














Please list all known Allergies

Order Information
Medication being ordered	Strength/Dose	Quantity	Generic substitution (Y/N)	Price (US$)	Country
			Yes No
			Yes No
			Yes No
			Yes No
			Yes No
			Yes No
			Yes No
			Yes No
			Yes No
			Yes No
			Yes No
			Yes No

We are required to dispense pills in child resistant containers unless indicated

Easy off caps				Shipping Charge: $9.50 US
Total: $ US

Credit Card Information
1. Cardholder(name on card)
2. Cardholder address
3. Credit card number
4. Cardholder city
5. Credit card expiry
6. Cardholder state
7. Cardholder Country
8. Cardholder zip code
Visa MasterCard
*Note in order to order from you must have been on the medication for a minimum of 30 days.
Informed consent for Patient Counseling:
We provide patient counseling from a licensed pharmacist on all prescriptions. This includes:

1. Medication identification (name, dose and use) 2. Directions for use and what to do if you miss a dose 3. Drug or food interactions and common side effects 4. Special storage requirements and refill information

When would you like a pharmacist to call you to discuss your medication?

Date:

User Agreement Form

No prescriptions will be filled without a signed and dated copy of this form

The undersigned, (hereinafter the "Patient") confirms that:

   1. The Patient is of the age of majority in the jurisdiction, in which the Patient resides and is fully competent to make their own        health care decisions.

   2. The Patient confirms that a duly qualified medical practitioner in the place of residence of the Patient prescribed the         pharmaceutical(s) ordered by the Patient (“the Ordered Product”). The Patient has not violated any laws in obtaining the         prescription and that the Ordered Product will not be used by no other person and in no manner except as prescribed by the         original prescribing physician ("The Patient's Physician").

   3. The Patient agrees to direct all questions to The Patient's Physician. The Patient will consult The Patient's Physician before        taking any new drug, natural product, or changing their daily health regiment.

   4. We requires the patient to submit a new medical questionnaire every time there is a change to their medical status. The        Patient understands that it is their responsibility to have The Patient's Physician conduct regular physical examinations        (minimum every 12 months), including any and all suggested testing by The Patient's Physician to ensure that they have no        medical problems which would constitute a contradiction to them taking medications prescribed for them. The Patient agrees        that should they suffer any adverse affects while taking any prescription medication that they will immediately contact The        Patient's Physician and that in the event they come under the care of another physician, the Patient will inform this        physician of any and all medications that have been prescribed.

   5. The Patient must take responsibility to secure their own medication stock from a local pharmacy in the interim if such an        event was to evolve, ensuring that at no point they are without medication.

   6. The Patient must honestly report all requested information and immediately update any changes to his or her record.

   7. The Patient understands that the Ordered Product may not be exchanged or returned or refund once purchased and shipped.

*BY SIGNING THIS DOCUMENT THE PATIENT CONFIRMS THAT HE OR SHE HAS READ AND UNDERSTOOD EACH OF THE ABOVE TERMS AND HAS AGREED TO EACH ONE.

  Name:

  (Signature)

Date: